Provider Demographics
NPI:1356513873
Name:ANTONIO MORAN JR MD FACP PC
Entity type:Organization
Organization Name:ANTONIO MORAN JR MD FACP PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:PAMELA
Authorized Official - Middle Name:
Authorized Official - Last Name:BENNETT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:912-261-4998
Mailing Address - Street 1:2500 STARLING ST
Mailing Address - Street 2:SUITE 303
Mailing Address - City:BRUNSWICK
Mailing Address - State:GA
Mailing Address - Zip Code:31520-4265
Mailing Address - Country:US
Mailing Address - Phone:912-261-4998
Mailing Address - Fax:912-261-4741
Practice Address - Street 1:2500 STARLING ST
Practice Address - Street 2:SUITE 303
Practice Address - City:BRUNSWICK
Practice Address - State:GA
Practice Address - Zip Code:31520-4265
Practice Address - Country:US
Practice Address - Phone:912-261-4998
Practice Address - Fax:912-261-4741
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-25
Last Update Date:2010-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA034669207RX0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RX0202XAllopathic & Osteopathic PhysiciansInternal MedicineMedical OncologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
511G700649Medicare PIN