Provider Demographics
NPI:1871716258
Name:HOLY FAMILY PEDIATRICS
Entity type:Organization
Organization Name:HOLY FAMILY PEDIATRICS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:ANTHONY
Authorized Official - Last Name:MOELL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:937-586-9665
Mailing Address - Street 1:359 FOREST AVE
Mailing Address - Street 2:SUITE 106
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45405-4563
Mailing Address - Country:US
Mailing Address - Phone:937-586-9665
Mailing Address - Fax:
Practice Address - Street 1:359 FOREST AVE
Practice Address - Street 2:SUITE 106
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45405-4563
Practice Address - Country:US
Practice Address - Phone:937-586-9665
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-11
Last Update Date:2008-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35062607-M174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2748736Medicaid
OH2748736Medicaid