Provider Demographics
NPI:1255043915
Name:MOOSALLY MEDICAL
Entity type:Organization
Organization Name:MOOSALLY MEDICAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:
Authorized Official - Last Name:MOOSALLY
Authorized Official - Suffix:JR
Authorized Official - Credentials:DO
Authorized Official - Phone:330-460-5514
Mailing Address - Street 1:8905 SOUTH ST SE
Mailing Address - Street 2:
Mailing Address - City:WARREN
Mailing Address - State:OH
Mailing Address - Zip Code:44484-2357
Mailing Address - Country:US
Mailing Address - Phone:330-402-3443
Mailing Address - Fax:
Practice Address - Street 1:2537 E MARKET ST
Practice Address - Street 2:
Practice Address - City:WARREN
Practice Address - State:OH
Practice Address - Zip Code:44483-6257
Practice Address - Country:US
Practice Address - Phone:330-460-5514
Practice Address - Fax:330-595-4366
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:COWFISH INDUSTRIES LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2022-12-14
Last Update Date:2022-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH374989Medicaid