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General NPI Number Information
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NPI Number | 1902003841
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Entity Type | Organization
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Legal Business Name | CHARLES B MOOMEY JR MD
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Dates
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Enumeration Date | 07/02/2007
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Last Update Date | 09/01/2010
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Provider Practice Location Address
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Address Line | 631 PROFESSIONAL DRIVE SUITE 300
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City | LAWRENCEVILLE
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State | GA
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Zip | 30046-3371
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Country | US
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Telephone | 770-962-9977
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Fax | 770-339-9804
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Provider Business Mailing Address
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Address Line | 631 PROFESSIONAL DRIVE SUITE 300
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City | LAWRENCEVILLE
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State | GA
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Zip | 30046-3371
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Country | US
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Telephone | 770-962-9977
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Fax | 770-339-9804
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Authorized Official
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Title or Position | OWNER
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Name | CHARLES BRUCE MOOMEY JR.
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Credential | M.D.
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Telephone | 770-962-9977
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2086S0129X
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Taxonomy Name | Vascular Surgery Physician
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License Number | 049923
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License Number State | GA
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