Provider Demographics
NPI:1992985014
Name:ROY R. MOELLER D.P.M. P.A.
Entity type:Organization
Organization Name:ROY R. MOELLER D.P.M. P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ATTORNEY FOR CORPORATION
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:A
Authorized Official - Last Name:BRANDELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:952-944-8344
Mailing Address - Street 1:7770 DELL RD
Mailing Address - Street 2:STE 140
Mailing Address - City:CHANHASSEN
Mailing Address - State:MN
Mailing Address - Zip Code:55317-9314
Mailing Address - Country:US
Mailing Address - Phone:952-934-9360
Mailing Address - Fax:952-975-0118
Practice Address - Street 1:7770 DELL RD
Practice Address - Street 2:STE 140
Practice Address - City:CHANHASSEN
Practice Address - State:MN
Practice Address - Zip Code:55317-9314
Practice Address - Country:US
Practice Address - Phone:952-934-9360
Practice Address - Fax:952-975-0118
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-06
Last Update Date:2008-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN396213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN203525100Medicaid
MN480000112Medicare PIN
MNT39925Medicare UPIN
MN203525100Medicaid