Healthcare Provider Details

I. General information

NPI: 1194169870
Provider Name (Legal Business Name): CAROLYN BAINDU MOORE M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/24/2013
Last Update Date: 11/13/2023
Certification Date: 11/13/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

720 WESTVIEW DR SW DEPARTMENT OF SURGERY
ATLANTA GA
30310-1458
US

IV. Provider business mailing address

145 HOSPITAL AVE STE 300
DU BOIS PA
15801-1465
US

V. Phone/Fax

Practice location:
  • Phone: 404-616-1426
  • Fax:
Mailing address:
  • Phone: 678-557-8078
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number2020020179
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code208G00000X
TaxonomyThoracic Surgery (Cardiothoracic Vascular Surgery) Physician
License NumberMD482549
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: