Provider Demographics
NPI:1366475030
Name:MORIARITY, RISA (MD)
Entity Type:Individual
Prefix:DR
First Name:RISA
Middle Name:
Last Name:MORIARITY
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 1:2500 N STATE ST
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39216-4500
Mailing Address - Country:US
Mailing Address - Phone:601-984-2538
Mailing Address - Fax:601-815-1854
Practice Address - Street 1:2500 N STATE ST
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39216-4500
Practice Address - Country:US
Practice Address - Phone:601-984-2538
Practice Address - Fax:601-815-1854
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-08
Last Update Date:2015-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS17704207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS05787589Medicaid
MSP00462291OtherRAILROAD MEDICARE
MSP01402393OtherRAILROAD MEDICARE
MS512G700003OtherMS MEDICARE - GROUP
MSP01402393OtherRAILROAD MEDICARE
MS05787589Medicaid
MS302I938844Medicare PIN