Healthcare Provider Details

I. General information

NPI: 1154302784
Provider Name (Legal Business Name): KEITH S MOORE M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/10/2005
Last Update Date: 11/30/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1100 JOHNSON FY RD NE SUITE 165
ATLANTA GA
30342-1709
US

IV. Provider business mailing address

1100 JOHNSON FY RD NE SUITE 165
ATLANTA GA
30342-1709
US

V. Phone/Fax

Practice location:
  • Phone: 404-446-2800
  • Fax: 404-446-2809
Mailing address:
  • Phone: 404-446-2800
  • Fax: 404-446-2809

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License NumberM8850
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: