1659737120 NPI number — RICHARD E MOORE MEDICAL PA

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1659737120 NPI number — RICHARD E MOORE MEDICAL PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
RICHARD E MOORE MEDICAL 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:
1659737120
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/13/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
523 HARKRIDER ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CONWAY
Provider Business Mailing Address State Name:
AR
Provider Business Mailing Address Postal Code:
72032-5631
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
501-327-4484
Provider Business Mailing Address Fax Number:
501-327-5963

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
523 HARKRIDER ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CONWAY
Provider Business Practice Location Address State Name:
AR
Provider Business Practice Location Address Postal Code:
72032-5631
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
501-327-4484
Provider Business Practice Location Address Fax Number:
501-327-5963
Provider Enumeration Date:
01/13/2016

Additional Information

Authorized Official

Authorized Official Last Name:
MCGUIRE
Authorized Official First Name:
TRYSTA
Authorized Official Middle Name:
Authorized Official Title or Position:
OFFICE ADMIN
Authorized Official Telephone Number:
501-733-0311

Provider Taxonomy Codes

  • Taxonomy code: 207LP2900X , with the licence number:  MC-3139 , registered in the state of AR ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207L00000X , with the licence number: MC-3139 , registered in the state of AR ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: MC-3139 . This is a "AR STATE MEDICAL BOARD LICENSE NUMBER" identifier , issued by the state of ( AR ) . This identifiers is of the category "OTHER".




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