Provider Demographics
NPI:1265480636
Name:MORAN, MARY MARGARET (MD)
Entity Type:Individual
Prefix:DR
First Name:MARY
Middle Name:MARGARET
Last Name:MORAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:210 PINE ST
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19106-4314
Mailing Address - Country:US
Mailing Address - Phone:215-762-3500
Mailing Address - Fax:215-762-1639
Practice Address - Street 1:231 N BROAD ST
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19107-1511
Practice Address - Country:US
Practice Address - Phone:215-523-6601
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD046318L208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0012994930007Medicaid
PA135836Medicare ID - Type Unspecified
PA0012994930007Medicaid