1881701308 NPI number — PAMELA M MOORE NP

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 1881701308 NPI number — PAMELA M MOORE NP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MOORE
Provider First Name:
PAMELA
Provider Middle Name:
M
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
NP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
YODER
Provider Other First Name:
PAMELA
Provider Other Middle Name:
M
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
ANP
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1881701308
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/28/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
611 W. PARK ST.
Provider Second Line Business Mailing Address:
BWPC
Provider Business Mailing Address City Name:
URBANA
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
61801-2500
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
217-383-6792
Provider Business Mailing Address Fax Number:
217-383-4752

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
611 W. PARK ST.
Provider Second Line Business Practice Location Address:
CARDIOLOGY
Provider Business Practice Location Address City Name:
URBANA
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
61801-2500
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
217-904-7000
Provider Business Practice Location Address Fax Number:
217-904-7742
Provider Enumeration Date:
08/23/2006

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: 2086S0129X , with the licence number:  RN81005 , registered in the state of AZ ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363LA2200X , with the licence number: 209-006880 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 103086 . This is a "MC COCHISE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 300051634 . This is a "MARICOPA FOUND" identifier . This identifiers is of the category "OTHER".
  • Identifier: 448664 . This is a "MERCY CARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 103087 . This is a "RR MC PIN" identifier , issued by the state of ( AZ ) . This identifiers is of the category "OTHER".
  • Identifier: 103087 . This is a "MC PIMA" identifier . This identifiers is of the category "OTHER".
  • Identifier: 1Z1408 . This is a "INTERGROUP HEALTHNET" identifier . This identifiers is of the category "OTHER".
  • Identifier: 300051634 . This is a "HUMANA" identifier . This identifiers is of the category "OTHER".
  • Identifier: 448664 . This is a "AHCCCS" identifier . This identifiers is of the category "OTHER".
  • Identifier: AZ0819900 . This is a "BCBS" identifier , issued by the state of ( AZ ) . This identifiers is of the category "OTHER".
  • Identifier: 300051634 . This is a "HEALTH PLAN AHP" identifier , issued by the state of ( AZ ) . This identifiers is of the category "OTHER".
  • Identifier: 300051634 . This is a "CIGNA" identifier . This identifiers is of the category "OTHER".
  • Identifier: 102542 . This is a "RR MC GRP" identifier , issued by the state of ( AZ ) . This identifiers is of the category "OTHER".
  • Identifier: 103086 . This is a "RR MC PIN" identifier , issued by the state of ( AZ ) . This identifiers is of the category "OTHER".
  • Identifier: 500005593 . This is a "TRAVELERS MC" identifier . This identifiers is of the category "OTHER".
  • Identifier: 300051634 . This is a "AETNA" identifier . This identifiers is of the category "OTHER".
  • Identifier: 448664 . This is a "INDIAN HEALTH" identifier . This identifiers is of the category "OTHER".
  • Identifier: 448664 , issued by the state of ( AZ ) . This identifiers is of the category "MEDICAID".




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