Provider Demographics
NPI:1750337762
Name:MOLONEY, BRIAN (MD)
Entity type:Individual
Prefix:
First Name:BRIAN
Middle Name:
Last Name:MOLONEY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 6309
Mailing Address - Street 2:
Mailing Address - City:SOUTH BEND
Mailing Address - State:IN
Mailing Address - Zip Code:46660-6309
Mailing Address - Country:US
Mailing Address - Phone:574-472-6700
Mailing Address - Fax:574-472-6746
Practice Address - Street 1:1122 S IRONWOOD DR
Practice Address - Street 2:
Practice Address - City:SOUTH BEND
Practice Address - State:IN
Practice Address - Zip Code:46615-1618
Practice Address - Country:US
Practice Address - Phone:574-472-6699
Practice Address - Fax:574-472-6698
Is Sole Proprietor?:No
Enumeration Date:2006-05-25
Last Update Date:2009-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01027627207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100222170AMedicaid
IN000000215987OtherBCBS
IN021236800OtherFEDERAL BLACK LUNG
IN187810BMedicare PIN
IN080181623Medicare PIN
IN000000215987OtherBCBS