1003816372 NPI number — CHARLES A MOORE MD

Table of content: CHARLES A MOORE MD (NPI 1003816372)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1003816372 NPI number — CHARLES A MOORE MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MOORE
Provider First Name:
CHARLES
Provider Middle Name:
A
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1003816372
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/27/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 309
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MIDDLESBORO
Provider Business Mailing Address State Name:
KY
Provider Business Mailing Address Postal Code:
40965-0309
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
606-248-0090
Provider Business Mailing Address Fax Number:
606-248-8803

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
123 N 19TH ST
Provider Second Line Business Practice Location Address:
SUITE 201
Provider Business Practice Location Address City Name:
MIDDLESBORO
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
40965-2865
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
606-248-0090
Provider Business Practice Location Address Fax Number:
606-248-8803
Provider Enumeration Date:
07/28/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207R00000X , with the licence number:  22757 , registered in the state of KY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 017423400 . This is a "BLACK LUNG" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: 1003816372 , issued by the state of ( KY ) . This identifiers is of the category "MEDICAID".
  • Identifier: 000000251586 . This is a "BLUE CROSS OF VA" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 1635649000 . This is a "DEPARTMENT OF LABOR" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: 000051203 . This is a "BLUE CROSS OF TENNESSEE" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".
  • Identifier: 000000062741 . This is a "BLUE CROSS OF KY" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: 110196198 . This is a "RAIL ROAD MEDICARE" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: 64227572 , issued by the state of ( KY ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1143 . This is a "CHA" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: 4176527 . This is a "TENNESSE MEDICAID" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".
  • Identifier: 1326780 . This is a "UMWA" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: 1659551935 . This is a "MEDICARE GROUP NPI" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: 006064205 . This is a "VA MEDICAID" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".




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