MEDICARE: BRIAN MOLONEY M.D.

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	207Q00000X	Family Medicine Physician	01027627	IN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	000000215987	OTHER	IN	BCBS
3	021236800	OTHER	IN	FEDERAL BLACK LUNG

General Provider Information

NPI Number	:	1750337762
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BRIAN MOLONEY M.D.

Provider Business Mailing Address
First Line	:	PO BOX 6309
Second Line	:
City	:	SOUTH BEND
State	:	IN
Zip	:	46660-6309
Country	:	US
Telephone Number	:	574-472-6700
Fax Number	:	574-472-6746

Provider Business Practice Location Address
First Line	:	1122 S IRONWOOD DR
Second Line	:
City	:	SOUTH BEND
State	:	IN
Zip	:	46615-1618
Country	:	US
Telephone Number	:	574-472-6699
Fax Number	:	574-472-6698

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

Provider Enumeration Date	:	05/25/2006
Last Update Date	:	02/25/2009

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Directions to “ BRIAN MOLONEY M.D.” Practice Location

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