1073500658 NPI number — JEANNE MOORE NP

Table of content: JEANNE MOORE NP (NPI 1073500658)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1073500658 NPI number — JEANNE MOORE NP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MOORE
Provider First Name:
JEANNE
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
NP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
MOORE
Provider Other First Name:
JEANNE
Provider Other Middle Name:
MARIE CARNEY
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
NP
Provider Other Last Name Type Code:
5

NPI Number Information

NPI Number:
1073500658
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/16/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2200 TACKETTS MILL DR
Provider Second Line Business Mailing Address:
WOODBRIDGE
Provider Business Mailing Address City Name:
WOODBRIDGE
Provider Business Mailing Address State Name:
VA
Provider Business Mailing Address Postal Code:
22192-3012
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
703-494-4961
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2200 TACKETTS MILL DR
Provider Second Line Business Practice Location Address:
WOODBRIDGE
Provider Business Practice Location Address City Name:
WOODBRIDGE
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
22192-3012
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
703-494-4961
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
09/29/2005

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: 363L00000X , with the licence number:  R 152237-0 , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363LF0000X , with the licence number: 0024168326 , registered in the state of VA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 23218 . This is a "SIOUX VALLEY HEALTH PLAN" identifier . This identifiers is of the category "OTHER".
  • Identifier: 984639500 , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1651881 . This is a "AMERICA'S PPO" identifier . This identifiers is of the category "OTHER".
  • Identifier: 141044 . This is a "UCARE MINNESOTA" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 500020824 . This is a "PALMETTO GBA RAILROAD MCR" identifier . This identifiers is of the category "OTHER".
  • Identifier: 01-07324 . This is a "MEDICA" identifier . This identifiers is of the category "OTHER".
  • Identifier: 062J3CA . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: NA2081029811 . This is a "PREFERRED ONE" identifier . This identifiers is of the category "OTHER".




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