Provider Demographics
NPI:1154592582
Name:G. MARK MORELAND M.D.
Entity type:Organization
Organization Name:G. MARK MORELAND M.D.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:GREGORY
Authorized Official - Middle Name:MARK
Authorized Official - Last Name:MORELAND
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:304-755-1571
Mailing Address - Street 1:2206 22ND ST
Mailing Address - Street 2:
Mailing Address - City:NITRO
Mailing Address - State:WV
Mailing Address - Zip Code:25143-1729
Mailing Address - Country:US
Mailing Address - Phone:304-755-1571
Mailing Address - Fax:304-755-3091
Practice Address - Street 1:2206 22ND ST
Practice Address - Street 2:
Practice Address - City:NITRO
Practice Address - State:WV
Practice Address - Zip Code:25143-1729
Practice Address - Country:US
Practice Address - Phone:304-755-1571
Practice Address - Fax:304-755-3091
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-13
Last Update Date:2008-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WVB 42708Medicare UPIN
WV9322221Medicare PIN