Provider Demographics
NPI:1659354215
Name:MOYNIHAN, HARRY LAWRENCE (MD)
Entity Type:Individual
Prefix:
First Name:HARRY
Middle Name:LAWRENCE
Last Name:MOYNIHAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1100 REID PARKWAY
Mailing Address - Street 2:MEDICAL STAFF SERVICE
Mailing Address - City:RICHMOND
Mailing Address - State:IN
Mailing Address - Zip Code:47374-1157
Mailing Address - Country:US
Mailing Address - Phone:765-935-8807
Mailing Address - Fax:
Practice Address - Street 1:1350 CHESTER BLVD STE B
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:IN
Practice Address - Zip Code:47374-1962
Practice Address - Country:US
Practice Address - Phone:765-935-4088
Practice Address - Fax:765-966-2596
Is Sole Proprietor?:No
Enumeration Date:2005-11-28
Last Update Date:2021-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01040503A208M00000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2189046Medicaid
IN100355090Medicaid
IN179230NMedicare PIN
OH2189046Medicaid