Provider Demographics
NPI:1902841059
Name:GREGG P. MOODY, PC
Entity Type:Organization
Organization Name:GREGG P. MOODY, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:GREGG
Authorized Official - Middle Name:P
Authorized Official - Last Name:MOODY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:256-233-2914
Mailing Address - Street 1:1005 W MARKET ST
Mailing Address - Street 2:SUITE 14
Mailing Address - City:ATHENS
Mailing Address - State:AL
Mailing Address - Zip Code:35611-2454
Mailing Address - Country:US
Mailing Address - Phone:256-233-2914
Mailing Address - Fax:256-230-9005
Practice Address - Street 1:1005 W MARKET ST
Practice Address - Street 2:SUITE 14
Practice Address - City:ATHENS
Practice Address - State:AL
Practice Address - Zip Code:35611-2454
Practice Address - Country:US
Practice Address - Phone:256-233-2914
Practice Address - Fax:256-230-9005
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-20
Last Update Date:2008-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL00027450207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL009937807Medicaid
K873Medicare PIN