=====================================================
General NPI Number Information
=====================================================
NPI Number | 1013574102
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MOON AND ASSOCIATES, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/23/2019
-----------------------------------------------------
Last Update Date | 09/20/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 12400 N MERIDIAN ST STE 100
-----------------------------------------------------
City | CARMEL
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 46032-4601
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 317-559-3320
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 12400 N MERIDIAN ST STE 100
-----------------------------------------------------
City | CARMEL
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 46032-4601
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MEMBER
-----------------------------------------------------
Name | AMY L HOLLAND
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 317-559-3320
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207V00000X
-----------------------------------------------------
Taxonomy Name | Obstetrics & Gynecology Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------