1700942786 NPI number — CRAIG K MOORE MD

Table of content: CRAIG K MOORE MD (NPI 1700942786)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1700942786 NPI number — CRAIG K MOORE MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MOORE
Provider First Name:
CRAIG
Provider Middle Name:
K
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:
1700942786
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/13/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 3175
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BELLINGHAM
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98227-3175
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
360-676-8476
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1401 6TH ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BELLINGHAM
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98225-7365
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
360-733-2904
Provider Business Practice Location Address Fax Number:
360-733-2909
Provider Enumeration Date:
12/28/2006

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: 207Q00000X , with the licence number:  AM0026894 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1302348 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".