Provider Demographics
NPI:1093879009
Name:NEW MOON MEDICAL, INC
Entity Type:Organization
Organization Name:NEW MOON MEDICAL, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:BEN
Authorized Official - Middle Name:
Authorized Official - Last Name:WORTHINGTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:859-737-5154
Mailing Address - Street 1:PO BOX 331
Mailing Address - Street 2:
Mailing Address - City:WINCHESTER
Mailing Address - State:KY
Mailing Address - Zip Code:40392-0331
Mailing Address - Country:US
Mailing Address - Phone:859-737-5154
Mailing Address - Fax:877-737-1881
Practice Address - Street 1:1210 W LEXINGTON AVE
Practice Address - Street 2:SUITE B
Practice Address - City:WINCHESTER
Practice Address - State:KY
Practice Address - Zip Code:40391-1127
Practice Address - Country:US
Practice Address - Phone:859-737-5154
Practice Address - Fax:877-737-1881
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-21
Last Update Date:2012-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY184257332B00000X
332BP3500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No332BP3500XSuppliersDurable Medical Equipment & Medical SuppliesParenteral & Enteral Nutrition
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY1865915OtherHIGHMARK BLUE SHIELD
KY393322OtherANTHEM PROVIDER #
KY90012758Medicaid
KY7436866OtherAETNA PIN #
KYD 5624460001OtherUNITED AMERICAN INSURANCE
KY7436866OtherAETNA PIN #
KY=========OtherHUMANA GOLD CHOICE
KY=========100OtherUNICARE
KY393322OtherANTHEM PROVIDER #
KY5624460001Medicare NSC