MEDICARE: DR. JOSE EMMANUEL MOULIER 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	2084P0804X	Child & Adolescent Psychiatry Physician	6177	PR

General Provider Information

NPI Number	:	1770583841
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JOSE EMMANUEL MOULIER M.D.

Provider Business Mailing Address
First Line	:	821 YOUNG WAY
Second Line	:
City	:	RICHMOND HILL
State	:	GA
Zip	:	31324-7239
Country	:	US
Telephone Number	:	912-756-4186
Fax Number	:	912-435-6053

Provider Business Practice Location Address
First Line	:	1061 HARMON AVE
Second Line	:	STE 1003
City	:	FORT STEWART
State	:	GA
Zip	:	31314-5604
Country	:	US
Telephone Number	:	912-435-6100
Fax Number	:	912-435-6053

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

Provider Enumeration Date	:	07/29/2005
Last Update Date	:	07/08/2007

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