Provider Demographics
NPI:1265038681
Name:MOEN, MD, PC
Entity Type:Organization
Organization Name:MOEN, MD, PC
Other - Org Name:PROSPERO HEALTH PARTNERS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:BILLING CREDENTIALING MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:KIMBERLY
Authorized Official - Middle Name:
Authorized Official - Last Name:MANN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:901-422-7608
Mailing Address - Street 1:50 S B B KING BLVD
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38103-2626
Mailing Address - Country:US
Mailing Address - Phone:901-422-7644
Mailing Address - Fax:
Practice Address - Street 1:4900 CALIFORNIA AVE
Practice Address - Street 2:TOWER B 2ND FLOOR
Practice Address - City:BAKERSFIELD
Practice Address - State:CA
Practice Address - Zip Code:93309
Practice Address - Country:US
Practice Address - Phone:901-438-6200
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-12-10
Last Update Date:2021-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207QH0002XAllopathic & Osteopathic PhysiciansFamily MedicineHospice and Palliative MedicineGroup - Multi-Specialty