Basic Information
| Provider Information | |||||||||
| NPI: | 1992201842 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MOORE | ||||||||
| FirstName: | ROSA | ||||||||
| MiddleName: | CHEREE | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | TOLOMELLO | ||||||||
| OtherFirstName: | ROSA | ||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
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| OtherCredential: | MD | ||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 329 SANCTUARY DR | ||||||||
| Address2: | |||||||||
| City: | CORTLAND | ||||||||
| State: | OH | ||||||||
| PostalCode: | 444108816 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | |||||||||
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| Practice Location | |||||||||
| Address1: | 6252 MAHONING AVE | ||||||||
| Address2: | |||||||||
| City: | AUSTINTOWN | ||||||||
| State: | OH | ||||||||
| PostalCode: | 445152003 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2406862300 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/31/2018 | ||||||||
| LastUpdateDate: | 07/06/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
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| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 07/06/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 207P00000X | 35.141492 | OH | Y | Allopathic & Osteopathic Physicians | Emergency Medicine |
No ID Information.