Provider Demographics
NPI:1902003841
Name:CHARLES B MOOMEY JR MD
Entity Type:Organization
Organization Name:CHARLES B MOOMEY JR MD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:BRUCE
Authorized Official - Last Name:MOOMEY
Authorized Official - Suffix:JR
Authorized Official - Credentials:MD
Authorized Official - Phone:770-962-9977
Mailing Address - Street 1:631 PROFESSIONAL DRIVE
Mailing Address - Street 2:SUITE 300
Mailing Address - City:LAWRENCEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30046-3371
Mailing Address - Country:US
Mailing Address - Phone:770-962-9977
Mailing Address - Fax:770-339-9804
Practice Address - Street 1:631 PROFESSIONAL DRIVE
Practice Address - Street 2:SUITE 300
Practice Address - City:LAWRENCEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30046-3371
Practice Address - Country:US
Practice Address - Phone:770-962-9977
Practice Address - Fax:770-339-9804
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-02
Last Update Date:2010-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA0499232086S0129X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00899951AMedicaid
GA00899951AMedicaid
GA02BDHZDMedicare PIN