Healthcare Provider Details

I. General information

NPI: 1093797136
Provider Name (Legal Business Name): JAMES L MOELLER MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/15/2005
Last Update Date: 02/09/2024
Certification Date: 02/09/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6040 UNIVERSITY TOWN CENTRE DR
MORGANTOWN WV
26501-2421
US

IV. Provider business mailing address

37000 WOODWARD AVE STE 300
BLOOMFIELD HILLS MI
48304-0922
US

V. Phone/Fax

Practice location:
  • Phone: 304-293-1020
  • Fax: 304-293-7042
Mailing address:
  • Phone: 248-952-9200
  • Fax: 248-952-9201

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License Number33178
License Number StateWV
# 2
Primary TaxonomyN
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License NumberJM063478
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: