Basic Information
| Provider Information | |||||||||
| NPI: | 1790124691 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MOONEY | ||||||||
| FirstName: | MICHAEL | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 60 FENWOOD RD | ||||||||
| Address2: | |||||||||
| City: | BOSTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 021156128 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2489330570 | ||||||||
| FaxNumber: | 6022948286 | ||||||||
| Practice Location | |||||||||
| Address1: | 60 FENWOOD RD | ||||||||
| Address2: | |||||||||
| City: | BOSTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 021156128 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2489330570 | ||||||||
| FaxNumber: | 6022948286 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/24/2013 | ||||||||
| LastUpdateDate: | 09/21/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 08/24/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207T00000X | MCS004591A | MA | N | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Neurological Surgery | 207T00000X | 281414 | MA | N | Allopathic & Osteopathic Physicians | Neurological Surgery | 207T00000X | 284117 | MA | Y | Allopathic & Osteopathic Physicians | Neurological Surgery |
ID Information
| ID | Type | State | Issuer | Description | R74142 | 01 | AZ | AZ TRAINING PERMIT | OTHER |