Healthcare Provider Details

I. General information

NPI: 1164647723
Provider Name (Legal Business Name): MOORE CLINIC INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/17/2007
Last Update Date: 12/21/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

209 MOLLER DRIVE
SITKA AK
99835
US

IV. Provider business mailing address

PO BOX 279
SITKA AK
99835-0279
US

V. Phone/Fax

Practice location:
  • Phone: 907-747-2616
  • Fax:
Mailing address:
  • Phone: 907-747-2616
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number227080
License Number StateAK
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number227080
License Number StateAK
# 3
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number227080
License Number StateAK
# 4
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number227080
License Number StateAK

VIII. Authorized Official

Name: DR. JOHN WILSON TOTTEN
Title or Position: PRESIDENT
Credential: MD FRCS
Phone: 907-747-3446