Basic Information
Provider Information | |||||||||
NPI: | 1003917154 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | MOORTHY MEDICAL ASSOCIATES, LLC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 643273 | ||||||||
Address2: |   | ||||||||
City: | CINCINNATI | ||||||||
State: | OH | ||||||||
PostalCode: | 452640307 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5138912813 | ||||||||
FaxNumber: | 5137931032 | ||||||||
Practice Location | |||||||||
Address1: | 311 NILLES RD | ||||||||
Address2: | STE G | ||||||||
City: | FAIRFIELD | ||||||||
State: | OH | ||||||||
PostalCode: | 450142636 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5138586555 | ||||||||
FaxNumber: | 5138586222 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 09/25/2006 | ||||||||
LastUpdateDate: | 11/30/2007 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | MOORTHY | ||||||||
AuthorizedOfficialFirstName: | PALANIVEL | ||||||||
AuthorizedOfficialMiddleName: | G | ||||||||
AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
AuthorizedOfficialTelephone: | 5138586555 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | DR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | MD | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207T00000X |   |   | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Neurological Surgery |   |
ID Information
ID | Type | State | Issuer | Description | DA5393 | 01 | OH | RR MEDICARE | OTHER |