Basic Information
| Provider Information | |||||||||
| NPI: | 1780662007 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MORIARTY | ||||||||
| FirstName: | JOSEPH | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 523 N 3RD ST | ||||||||
| Address2: | |||||||||
| City: | BRAINERD | ||||||||
| State: | MN | ||||||||
| PostalCode: | 564013054 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2188292861 | ||||||||
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| Practice Location | |||||||||
| Address1: | 13060 ISLE DR | ||||||||
| Address2: | |||||||||
| City: | BAXTER | ||||||||
| State: | MN | ||||||||
| PostalCode: | 564258331 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2188282880 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/06/2006 | ||||||||
| LastUpdateDate: | 01/08/2016 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 40765 | MN | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 640018300 | 05 | MN | MEDICAID |