Healthcare Provider Details

I. General information

NPI: 1497161046
Provider Name (Legal Business Name): BRIAN J MOORE D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/03/2014
Last Update Date: 01/17/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

UNIVERSITY OF KENTUCKY 800 ROSE ST
LEXINGTON KY
40536-9203
US

IV. Provider business mailing address

138 LEADER AVE RM 9A
LEXINGTON KY
40508-3215
US

V. Phone/Fax

Practice location:
  • Phone: 859-323-2636
  • Fax:
Mailing address:
  • Phone: 859-218-3895
  • Fax: 859-257-1439

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number04133
License Number StateKY
# 2
Primary TaxonomyN
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number04133
License Number StateKY
# 3
Primary TaxonomyY
Taxonomy Code2080N0001X
TaxonomyNeonatal-Perinatal Medicine Physician
License Number04133
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: