Healthcare Provider Details

I. General information

NPI: 1871554527
Provider Name (Legal Business Name): BRIAN HAROLD MOORE M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/31/2006
Last Update Date: 05/23/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

813 W 2ND ST
BLOOMINGTON IN
47403-2212
US

IV. Provider business mailing address

813 W 2ND ST
BLOOMINGTON IN
47403-2212
US

V. Phone/Fax

Practice location:
  • Phone: 812-330-0303
  • Fax: 812-330-0404
Mailing address:
  • Phone: 812-330-0303
  • Fax: 812-330-0404

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number01060196A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: