Provider Demographics
NPI:1003958117
Name:MORIAH
Entity Type:Organization
Organization Name:MORIAH
Other - Org Name:DR. TIM JACKSON
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:TIMOTHY
Authorized Official - Middle Name:D
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:228-832-9933
Mailing Address - Street 1:PO BOX 10049
Mailing Address - Street 2:
Mailing Address - City:GULFPORT
Mailing Address - State:MS
Mailing Address - Zip Code:39505-0049
Mailing Address - Country:US
Mailing Address - Phone:228-832-9933
Mailing Address - Fax:228-832-9916
Practice Address - Street 1:12080 NEW ORLEANS AVE N
Practice Address - Street 2:
Practice Address - City:GULFPORT
Practice Address - State:MS
Practice Address - Zip Code:39503-3180
Practice Address - Country:US
Practice Address - Phone:228-832-9933
Practice Address - Fax:228-832-9916
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-13
Last Update Date:2008-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS14510174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00124986Medicaid
MS4462430001Medicare NSC
MSG11631Medicare UPIN
MS00124986Medicaid