Basic Information
| Provider Information | |||||||||
| NPI: | 1649255753 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MORITZ | ||||||||
| FirstName: | JOHN | ||||||||
| MiddleName: | BRADLEY | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 13221 RAVENNA RD | ||||||||
| Address2: | SUITE 8 | ||||||||
| City: | CHARDON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 440249047 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4402866155 | ||||||||
| FaxNumber: | 4402866156 | ||||||||
| Practice Location | |||||||||
| Address1: | 13221 RAVENNA RD | ||||||||
| Address2: | SUITE 8 | ||||||||
| City: | CHARDON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 440249047 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4402866155 | ||||||||
| FaxNumber: | 4402866156 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/12/2005 | ||||||||
| LastUpdateDate: | 01/15/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 01/15/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 35056678 | OH | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 080153957 | 01 | OH | RAILROAD MEDICARE | OTHER | 0737313 | 05 | OH | MEDICAID |