Provider Demographics
NPI:1013993419
Name:MOOSALLY, ROBERT T (DO)
Entity Type:Individual
Prefix:MR
First Name:ROBERT
Middle Name:T
Last Name:MOOSALLY
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5700 DARROW RD
Mailing Address - Street 2:STE 106
Mailing Address - City:HUDSON
Mailing Address - State:OH
Mailing Address - Zip Code:44236-5021
Mailing Address - Country:US
Mailing Address - Phone:330-656-5911
Mailing Address - Fax:330-656-5901
Practice Address - Street 1:667 EASTLAND AVE SE
Practice Address - Street 2:
Practice Address - City:WARREN
Practice Address - State:OH
Practice Address - Zip Code:44484-4503
Practice Address - Country:US
Practice Address - Phone:330-841-4000
Practice Address - Fax:330-841-4007
Is Sole Proprietor?:No
Enumeration Date:2005-12-16
Last Update Date:2008-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH34007710207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH000000385522OtherANTHEM
OH2374989Medicaid
OH001965500-0003OtherPENNSYLVANIA MEDICAID
OH000000383091OtherANTHEM
OHP00141425Medicare PIN
OH000000385522OtherANTHEM
H76888Medicare UPIN
OHMO4132751Medicare PIN