1003824004 NPI number — WAYNE E MOORE MD

Table of content: WAYNE E MOORE MD (NPI 1003824004)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1003824004 NPI number — WAYNE E MOORE MD

Organization/Personal Information

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

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:
1003824004
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/07/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
P.O. BOX 1690
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LAPORTE
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
46352-1690
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
219-326-2312
Provider Business Mailing Address Fax Number:
219-326-2584

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
901 LINCOLNWAY
Provider Second Line Business Practice Location Address:
STE 304
Provider Business Practice Location Address City Name:
LAPORTE
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
46350
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
219-362-8523
Provider Business Practice Location Address Fax Number:
219-324-9396
Provider Enumeration Date:
08/04/2006

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: 208600000X , with the licence number:  IN01038003A , 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: 01038003 . This is a "LICENSE NUMBER" identifier . This identifiers is of the category "OTHER".
  • Identifier: 100367770A , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 01038003B . This is a "CSR" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".




Copyright © 2007-2025 www.npivalidator.com