1205060167 NPI number — ELISABETH MOORE MD

Table of content: ELISABETH MOORE MD (NPI 1205060167)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1205060167 NPI number — ELISABETH MOORE MD

Organization/Personal Information

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

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
PIERSON
Provider Other First Name:
ELISABETH
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
MD
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1205060167
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/10/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
189 PROUTY DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
NEWPORT
Provider Business Mailing Address State Name:
VT
Provider Business Mailing Address Postal Code:
05855-9326
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
802-334-7900
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
59 PAGE HILL RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BERLIN
Provider Business Practice Location Address State Name:
NH
Provider Business Practice Location Address Postal Code:
03570-3531
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
603-752-2200
Provider Business Practice Location Address Fax Number:
603-752-1836
Provider Enumeration Date:
05/07/2009

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: 207P00000X , with the licence number:  18810 , registered in the state of NH ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 207P00000X , with the licence number: 042-0012485 , registered in the state of VT ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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