MEDICARE: DOUGLAS BOYLSTON MOORE III MD

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	207Q00000X	Family Medicine Physician	32634	SC

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1396064804
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DOUGLAS BOYLSTON MOORE III MD

Provider Business Mailing Address
First Line	:	901 W GREENWOOD ST
Second Line	:	SUITE 9
City	:	ABBEVILLE
State	:	SC
Zip	:	29620-5717
Country	:	US
Telephone Number	:	864-366-9681
Fax Number	:	864-366-5600

Provider Business Practice Location Address
First Line	:	901 W GREENWOOD ST
Second Line	:	SUITE 9
City	:	ABBEVILLE
State	:	SC
Zip	:	29620-5717
Country	:	US
Telephone Number	:	864-366-9681
Fax Number	:	864-366-5600

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

Provider Enumeration Date	:	05/24/2010
Last Update Date	:	01/06/2023

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