Healthcare Provider Details

I. General information

NPI: 1679519367
Provider Name (Legal Business Name): RICHARD E MOORE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/21/2006
Last Update Date: 04/07/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6156 W EMERALD STREET
BOISE ID
83704-8613
US

IV. Provider business mailing address

3340 E GOLDSTONE WAY
MERIDIAN ID
83642-1026
US

V. Phone/Fax

Practice location:
  • Phone: 208-377-0777
  • Fax: 208-377-1070
Mailing address:
  • Phone: 208-377-0777
  • Fax: 208-377-1070

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License NumberM5456
License Number StateID
# 2
Primary TaxonomyN
Taxonomy Code207XS0114X
TaxonomyAdult Reconstructive Orthopaedic Surgery Physician
License NumberM5456
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: