1104811215 NPI number — JILL M MOORE FNP-BC

Table of content: JILL M MOORE FNP-BC (NPI 1104811215)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1104811215 NPI number — JILL M MOORE FNP-BC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MOORE
Provider First Name:
JILL
Provider Middle Name:
M
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
FNP-BC
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:
1104811215
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/06/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 779
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
TAWAS CITY
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48764-0779
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
855-298-9888
Provider Business Mailing Address Fax Number:
989-497-3162

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1212 W SAGINAW RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
VASSAR
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48768-9483
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
989-823-5020
Provider Business Practice Location Address Fax Number:
989-823-7881
Provider Enumeration Date:
09/14/2005

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: 363LF0000X , with the licence number:  4704173083 , 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: M10200335 . This is a "TRICARE" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 150533 . This is a "MEDICAID-GREATLAKES" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 0877585 . This is a "BCBSMI" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 4708328 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".




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