Provider Demographics
NPI:1275526485
Name:MORIARTY, THOMAS M (MD PHD)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:M
Last Name:MORIARTY
Suffix:
Gender:M
Credentials:MD PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 776351
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60677-6351
Mailing Address - Country:US
Mailing Address - Phone:502-588-9490
Mailing Address - Fax:502-272-5116
Practice Address - Street 1:210 E GRAY ST
Practice Address - Street 2:SUITE 1105
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40202-3900
Practice Address - Country:US
Practice Address - Phone:502-583-1609
Practice Address - Fax:502-583-2120
Is Sole Proprietor?:No
Enumeration Date:2005-08-24
Last Update Date:2016-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY33517207T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY00533112OtherMEDICARE - KY - NNIKY
KY000000604406OtherANTHEM - NNIKY
IN200155550Medicaid
KY102716OtherSIHO - NNIKY
KY7354921OtherCIGNA - NNIKY
KY3694171000OtherPASSPORT ADVTG - NNIKY
KY000023035HOtherHUMANA - NNIKY
KY50022352OtherPASSPORT - NNIKY
KY64353170Medicaid
IN200155550Medicaid
KY000000604406OtherANTHEM - NNIKY