1902881220 NPI number — ROXANN MOORE OTR/MHS

Table of content: ROXANN MOORE OTR/MHS (NPI 1902881220)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1902881220 NPI number — ROXANN MOORE OTR/MHS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MOORE
Provider First Name:
ROXANN
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
OTR/MHS
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:
ROXANN
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
OTR/MHS
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1902881220
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/28/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3000 S STATE ROAD 135
Provider Second Line Business Mailing Address:
STE 110
Provider Business Mailing Address City Name:
GREENWOOD
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
46143-9829
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
317-535-4075
Provider Business Mailing Address Fax Number:
317-535-4076

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1800 S 3RD ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
TERRE HAUTE
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
47802-1920
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
812-232-4036
Provider Business Practice Location Address Fax Number:
812-235-0420
Provider Enumeration Date:
12/09/2005

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: 225X00000X , with the licence number:  31001814A , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 000000316207 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".