MEDICARE: DR. CHARLES S MOORE 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	2013017434	MO

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

General Provider Information

NPI Number	:	1902877012
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. CHARLES S MOORE MD

Provider Business Mailing Address
First Line	:	12700 SOUTHFORK RD STE 175
Second Line	:
City	:	SAINT LOUIS
State	:	MO
Zip	:	63128-3209
Country	:	US
Telephone Number	:	314-525-1798
Fax Number	:	314-525-4469

Provider Business Practice Location Address
First Line	:	12700 SOUTHFORK RD STE 175
Second Line	:
City	:	SAINT LOUIS
State	:	MO
Zip	:	63128-3209
Country	:	US
Telephone Number	:	314-525-1798
Fax Number	:	314-525-4469

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

Provider Enumeration Date	:	01/27/2006
Last Update Date	:	05/01/2025

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Directions to “ DR. CHARLES S MOORE MD” Practice Location

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