Healthcare Provider Details

I. General information

NPI: 1003816372
Provider Name (Legal Business Name): CHARLES A MOORE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/28/2005
Last Update Date: 04/27/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

123 N 19TH ST SUITE 201
MIDDLESBORO KY
40965-2865
US

IV. Provider business mailing address

PO BOX 309
MIDDLESBORO KY
40965-0309
US

V. Phone/Fax

Practice location:
  • Phone: 606-248-0090
  • Fax: 606-248-8803
Mailing address:
  • Phone: 606-248-0090
  • Fax: 606-248-8803

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number22757
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: