Provider Demographics
NPI:1982885976
Name:MICHELLE MORAN MD PC
Entity Type:Organization
Organization Name:MICHELLE MORAN MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHELLE
Authorized Official - Middle Name:RUTH
Authorized Official - Last Name:MORAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:719-328-9653
Mailing Address - Street 1:PO BOX 38969
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80937-8969
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:716 N TEJON ST
Practice Address - Street 2:STE 4
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80903-1012
Practice Address - Country:US
Practice Address - Phone:719-328-9653
Practice Address - Fax:719-328-9738
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-18
Last Update Date:2007-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COMD 39135103TP0016X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TP0016XBehavioral Health & Social Service ProvidersPsychologistPrescribing (Medical)Group - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO10686045Medicaid
CO10686045Medicaid
COC550538Medicare PIN