MEDICARE: DR. MYRON ERNEST MOOREHEAD II MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207VG0400X	Gynecology Physician	MD4222R	LA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	092522606	OTHER	LA	CONTROLLED SUBSTANCE LIC

General Provider Information

NPI Number	:	1104993708
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MYRON ERNEST MOOREHEAD II MD

Provider Business Mailing Address
First Line	:	200 W ESPLANADE AVE
Second Line	:	SUITE 311
City	:	KENNER
State	:	LA
Zip	:	70065-2474
Country	:	US
Telephone Number	:	504-467-0770
Fax Number	:	504-467-0791

Provider Business Practice Location Address
First Line	:	200 W ESPLANADE AVE
Second Line	:	SUITE 311
City	:	KENNER
State	:	LA
Zip	:	70065-2474
Country	:	US
Telephone Number	:	504-467-0770
Fax Number	:	504-467-0791

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/29/2006
Last Update Date	:	09/20/2016

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