1265542245 NPI number — MS. FREADDIE V MOORE CRNA

Table of content: MS. FREADDIE V MOORE CRNA (NPI 1265542245)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1265542245 NPI number — MS. FREADDIE V MOORE CRNA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MOORE
Provider First Name:
FREADDIE
Provider Middle Name:
V
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
CRNA
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
HART
Provider Other First Name:
FREADDIE
Provider Other Middle Name:
V
Provider Other Name Prefix Text:
MRS.
Provider Other Name Suffix Text:
Provider Other Credential Text:
CRNA
Provider Other Last Name Type Code:
5

NPI Number Information

NPI Number:
1265542245
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/30/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
804 SCOTT NIXON MEMORIAL DRIVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
AUGUSTA
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30907-2464
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
800-394-4445
Provider Business Mailing Address Fax Number:
706-650-1034

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
30200 TELEGRAPH ROAD
Provider Second Line Business Practice Location Address:
220
Provider Business Practice Location Address City Name:
BINGHAM FARMS
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48025-4502
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
248-258-5058
Provider Business Practice Location Address Fax Number:
248-927-5058
Provider Enumeration Date:
08/30/2006

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: 367H00000X , with the licence number:  4704100987 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 367500000X , with the licence number: 4704100987 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 4834216-10 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 11802435 . This is a "CAQH" identifier . This identifiers is of the category "OTHER".




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