MEDICARE: SUSAN J 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	208000000X	Pediatrics Physician	MD044660E	PA

General Provider Information

NPI Number	:	1912982661
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SUSAN J MOORE MD

Provider Business Mailing Address
First Line	:	4247 W RIDGE RD STE 105
Second Line	:
City	:	ERIE
State	:	PA
Zip	:	16506-1746
Country	:	US
Telephone Number	:	814-838-2468
Fax Number	:	814-835-2599

Provider Business Practice Location Address
First Line	:	4247 W RIDGE RD STE 105
Second Line	:
City	:	ERIE
State	:	PA
Zip	:	16506-1746
Country	:	US
Telephone Number	:	814-838-2468
Fax Number	:	814-835-2599

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

Provider Enumeration Date	:	12/14/2005
Last Update Date	:	10/07/2020

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