1578606612 NPI number — MRS. MARGUERITE THERESA MOORE PH.D, ATC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1578606612 NPI number — MRS. MARGUERITE THERESA MOORE PH.D, ATC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MOORE
Provider First Name:
MARGUERITE
Provider Middle Name:
THERESA
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
PH.D, ATC
Provider Gender Code:
F

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:
1578606612
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/05/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
47 WHITE OAK DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MARQUETTE
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
49855-9450
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
906-226-4549
Provider Business Mailing Address Fax Number:
906-227-2181

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1401 PRESQUE ISLE, NORTHERN MICHIGAN UNIVERSITY
Provider Second Line Business Practice Location Address:
SCHOOL OF HEALTH AND HUMAN PERFORMANCE, PEIF BUILDING
Provider Business Practice Location Address City Name:
MARQUETTE
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
49855-2634
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
906-227-2239
Provider Business Practice Location Address Fax Number:
906-227-2181
Provider Enumeration Date:
02/15/2007

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: 2255A2300X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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