1629062807 NPI number — MR. BRADLEY T MOORE DO

Table of content: MR. BRADLEY T MOORE DO (NPI 1629062807)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1629062807 NPI number — MR. BRADLEY T MOORE DO

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MOORE
Provider First Name:
BRADLEY
Provider Middle Name:
T
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
DO
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:
1629062807
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/13/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
62 KY RTE 306
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BYPRO
Provider Business Mailing Address State Name:
KY
Provider Business Mailing Address Postal Code:
41612
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
606-452-1700
Provider Business Mailing Address Fax Number:
606-452-1703

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
62 KY RTE 306
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BYPRO
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
41612
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
606-452-1700
Provider Business Practice Location Address Fax Number:
606-452-1703
Provider Enumeration Date:
09/02/2005

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: 207Q00000X , with the licence number:  02916 , registered in the state of KY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 64106719 , issued by the state of ( KY ) . This identifiers is of the category "MEDICAID".




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