1386866572 NPI number — ANDREW MOORE

Table of content: ANDREW MOORE (NPI 1386866572)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1386866572 NPI number — ANDREW MOORE

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MOORE
Provider First Name:
ANDREW
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
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:
1386866572
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/23/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1900 N STATE ST STE 105
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PROVO
Provider Business Mailing Address State Name:
UT
Provider Business Mailing Address Postal Code:
84604-1354
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
801-655-5245
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1900 N STATE ST STE 105
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PROVO
Provider Business Practice Location Address State Name:
UT
Provider Business Practice Location Address Postal Code:
84604-1354
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
801-655-5245
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
05/03/2007

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: 207VE0102X , with the licence number:  8198024-1205 , registered in the state of UT ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 0722557 . This is a "MEDICARE - FOUNDATION" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: 3726872000 . This is a "PASSPORT ADVANTAGE PCP" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: 000000610833 . This is a "ANTHEM" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: 3726871000 . This is a "PASSPORT ADVANTAGE SPECIALITY" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: 9328408 . This is a "AETNA" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: 3726875000 . This is a "PASSPORT ADVANTAGE" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: 7100074130 , issued by the state of ( KY ) . This identifiers is of the category "MEDICAID".
  • Identifier: 50024901 . This is a "PASSPORT SPECIALTY" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: 50024902 . This is a "PASSPORT PCP" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: 000000610836 . This is a "ANTHEM" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: 50024905 . This is a "PASSPORT SPECIALITY" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: 200947330 , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".




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