=====================================================
General NPI Number Information
=====================================================
NPI Number | 1386035954
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | TIM I MOOMAW NP
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/18/2015
-----------------------------------------------------
Last Update Date | 02/18/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 100 JACKSON PIKE
-----------------------------------------------------
City | GALLIPOLIS
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 45631-1560
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 740-446-5000
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 75 REMIT DR #1367
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60675-1367
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 866-916-5259
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363L00000X
-----------------------------------------------------
Taxonomy Name | Nurse Practitioner
-----------------------------------------------------
License Number | COA.17111-NP
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------