Provider Demographics
NPI:1053356170
Name:MOELLER, HENRY EDWARD (MD)
Entity type:Individual
Prefix:
First Name:HENRY
Middle Name:EDWARD
Last Name:MOELLER
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 1:100 E LIBERTY ST STE 800
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40202-1428
Mailing Address - Country:US
Mailing Address - Phone:502-647-4085
Mailing Address - Fax:502-647-4098
Practice Address - Street 1:727 HOSPITAL DR
Practice Address - Street 2:
Practice Address - City:SHELBYVILLE
Practice Address - State:KY
Practice Address - Zip Code:40065
Practice Address - Country:US
Practice Address - Phone:502-647-4085
Practice Address - Fax:502-647-4098
Is Sole Proprietor?:No
Enumeration Date:2006-06-20
Last Update Date:2019-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY37945207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64065147Medicaid
IN200438870AMedicaid
KY0609049Medicare Oscar/Certification
KYP00016064Medicare PIN
KY64065147Medicaid