Provider Demographics
NPI:1497059562
Name:MARIA A MOOGERFELD MD, LLC
Entity Type:Organization
Organization Name:MARIA A MOOGERFELD MD, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:NICHOLE
Authorized Official - Middle Name:HOPE
Authorized Official - Last Name:HADDOCK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:912-681-7111
Mailing Address - Street 1:1088A BERMUDA RUN
Mailing Address - Street 2:
Mailing Address - City:STATESBORO
Mailing Address - State:GA
Mailing Address - Zip Code:30458-0858
Mailing Address - Country:US
Mailing Address - Phone:912-681-7111
Mailing Address - Fax:912-871-7794
Practice Address - Street 1:1088A BERMUDA RUN
Practice Address - Street 2:
Practice Address - City:STATESBORO
Practice Address - State:GA
Practice Address - Zip Code:30458-0858
Practice Address - Country:US
Practice Address - Phone:912-681-7111
Practice Address - Fax:912-871-7794
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-01-05
Last Update Date:2011-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA051893207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty