Healthcare Provider Details

I. General information

NPI: 1659737120
Provider Name (Legal Business Name): RICHARD E MOORE MEDICAL PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/13/2016
Last Update Date: 01/13/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

523 HARKRIDER ST
CONWAY AR
72032-5631
US

IV. Provider business mailing address

523 HARKRIDER ST
CONWAY AR
72032-5631
US

V. Phone/Fax

Practice location:
  • Phone: 501-327-4484
  • Fax: 501-327-5963
Mailing address:
  • Phone: 501-327-4484
  • Fax: 501-327-5963

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207LP2900X
TaxonomyPain Medicine (Anesthesiology) Physician
License NumberMC-3139
License Number StateAR
# 2
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License NumberMC-3139
License Number StateAR

VIII. Authorized Official

Name: MRS. TRYSTA MCGUIRE
Title or Position: OFFICE ADMIN
Credential:
Phone: 501-733-0311