MEDICARE: DR. BROOKE CAROL MOORE M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207RN0300X	Nephrology Physician	161222	NY

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
4	390001418	OTHER	NM	MEDICARE RAIL ROAD

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	CS629	OTHER	NY	OXFORD
2	0C3233	OTHER	NY	HEALTHNET
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1205833704
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. BROOKE CAROL MOORE M.D.

Provider Business Mailing Address
First Line	:	1500 ROUTE 112 STE 101
Second Line	:
City	:	PORT JEFFERSON STATION
State	:	NY
Zip	:	11776-8054
Country	:	US
Telephone Number	:	631-751-3000
Fax Number	:	631-509-6559

Provider Business Practice Location Address
First Line	:	2500 ROUTE 347
Second Line	:	BLDG 14A
City	:	STONY BROOK
State	:	NY
Zip	:	11790-2554
Country	:	US
Telephone Number	:	631-689-7800
Fax Number	:	631-689-3016

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/30/2005
Last Update Date	:	09/20/2019

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Directions to “ DR. BROOKE CAROL MOORE M.D.” Practice Location

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