1639407323 NPI number — M B MOORE MD ORTHOPAEDIC SURGEON PA

Table of content: (NPI 1639407323)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1639407323 NPI number — M B MOORE MD ORTHOPAEDIC SURGEON PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
M B MOORE MD ORTHOPAEDIC SURGEON PA
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

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:
1639407323
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/25/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 9178
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
RUSSELLVILLE
Provider Business Mailing Address State Name:
AR
Provider Business Mailing Address Postal Code:
72811-9178
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
479-968-4273
Provider Business Mailing Address Fax Number:
479-968-1363

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
628 HOSPITAL DR
Provider Second Line Business Practice Location Address:
SUITE E
Provider Business Practice Location Address City Name:
MOUNTAIN HOME
Provider Business Practice Location Address State Name:
AR
Provider Business Practice Location Address Postal Code:
72653-2953
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
870-424-4710
Provider Business Practice Location Address Fax Number:
870-424-4780
Provider Enumeration Date:
11/18/2009

Additional Information

Authorized Official

Authorized Official Last Name:
MOORE
Authorized Official First Name:
MERWIN
Authorized Official Middle Name:
B
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
870-424-4710

Provider Taxonomy Codes

  • Taxonomy code: 207X00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 180094002 , issued by the state of ( AR ) . This identifiers is of the category "MEDICAID".
  • Identifier: 5G230 . This is a "BCBS" identifier , issued by the state of ( AR ) . This identifiers is of the category "OTHER".




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