Healthcare Provider Details

I. General information

NPI: 1881657260
Provider Name (Legal Business Name): MERWIN B MOORE III MD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/07/2006
Last Update Date: 08/26/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

628 HOSPITAL DR STE E
MOUNTAIN HOME AR
72653-2953
US

IV. Provider business mailing address

PO BOX 9178
RUSSELLVILLE AR
72811-9178
US

V. Phone/Fax

Practice location:
  • Phone: 870-424-4710
  • Fax: 870-424-4780
Mailing address:
  • Phone: 479-968-4273
  • Fax: 479-968-1363

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number2003027560
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State

VIII. Authorized Official

Name: MR. MERWIN MOORE
Title or Position: OWNER
Credential: MD
Phone: 870-424-4710