Provider Demographics
NPI:1043329881
Name:MOSES FAMILY MEDICINE, INC.
Entity Type:Organization
Organization Name:MOSES FAMILY MEDICINE, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MELIN
Authorized Official - Middle Name:JONATHAN
Authorized Official - Last Name:MOSES
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:304-781-3589
Mailing Address - Street 1:2959 3RD AVE
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON
Mailing Address - State:WV
Mailing Address - Zip Code:25702-1401
Mailing Address - Country:US
Mailing Address - Phone:304-781-3589
Mailing Address - Fax:
Practice Address - Street 1:2959 3RD AVE
Practice Address - Street 2:
Practice Address - City:HUNTINGTON
Practice Address - State:WV
Practice Address - Zip Code:25702-1401
Practice Address - Country:US
Practice Address - Phone:304-781-3589
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-29
Last Update Date:2008-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV19364173000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes173000000XOther Service ProvidersLegal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0055289000Medicaid
WV001858663OtherBC/BS
WVM09364931Medicare PIN
WV001858663OtherBC/BS