Basic Information
| Provider Information | |||||||||
| NPI: | 1083773709 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MOA MEDICAL MANAGEMENT, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 108809 | ||||||||
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| City: | OKLAHOMA CITY | ||||||||
| State: | OK | ||||||||
| PostalCode: | 731018809 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9724791115 | ||||||||
| FaxNumber: | 9724791118 | ||||||||
| Practice Location | |||||||||
| Address1: | 5920 FOREST PARK RD | ||||||||
| Address2: | STE. 560 | ||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 75218 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2143500708 | ||||||||
| FaxNumber: | 2143500712 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/08/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | HOBBS | ||||||||
| AuthorizedOfficialFirstName: | GRADY | ||||||||
| AuthorizedOfficialMiddleName: | LAWSON | ||||||||
| AuthorizedOfficialTitleorPosition: | VP OPERATIONS | ||||||||
| AuthorizedOfficialTelephone: | 4696826743 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2471M1202X | Y | 193400000X SINGLE SPECIALTY GROUP | Technologists, Technicians & Other Technical Service Providers | Radiologic Technologist | Magnetic Resonance Imaging |
No ID Information.