Provider Demographics
NPI:1972502722
Name:MOOSNICK, MIRIAM (DO)
Entity Type:Individual
Prefix:DR
First Name:MIRIAM
Middle Name:
Last Name:MOOSNICK
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3200 VINE ST
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45220-2213
Mailing Address - Country:US
Mailing Address - Phone:513-861-3100
Mailing Address - Fax:
Practice Address - Street 1:7711 EWING BLVD
Practice Address - Street 2:
Practice Address - City:FLORENCE
Practice Address - State:KY
Practice Address - Zip Code:41042-7533
Practice Address - Country:US
Practice Address - Phone:859-282-4480
Practice Address - Fax:859-282-0297
Is Sole Proprietor?:No
Enumeration Date:2005-07-14
Last Update Date:2011-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS0007970207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLE7629BMedicare ID - Type Unspecified
FLH64284Medicare UPIN