Provider Demographics
NPI:1134199243
Name:MORELAND, GREGORY MARK (MD)
Entity type:Individual
Prefix:MR
First Name:GREGORY
Middle Name:MARK
Last Name:MORELAND
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
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
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-23
Last Update Date:2008-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV14373207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0052030000Medicaid
B42708Medicare UPIN
WV0052030000Medicaid