Healthcare Provider Details

I. General information

NPI: 1578544672
Provider Name (Legal Business Name): CAROLYN MOORE MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/07/2005
Last Update Date: 09/22/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

155 BRICKLAYER STREET
OLIVE HILL KY
41164
US

IV. Provider business mailing address

PO BOX 1268
OLIVE HILL KY
41164-1268
US

V. Phone/Fax

Practice location:
  • Phone: 606-286-4152
  • Fax: 606-286-2385
Mailing address:
  • Phone: 606-286-4152
  • Fax: 606-286-2385

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number30072
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: