Healthcare Provider Details

I. General information

NPI: 1154617058
Provider Name (Legal Business Name): JACOB E MOORE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/20/2011
Last Update Date: 05/12/2026
Certification Date: 05/12/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

GSMC - EMERGENCY DEPARTMENT 235 NORTH PEARL ST
BROCKTON MA
02301
US

IV. Provider business mailing address

BMCHS PROVIDER ENROLLMENT 960 MASSACHUSETTS AVE FLR 2
BOSTON MA
02118
US

V. Phone/Fax

Practice location:
  • Phone: 508-427-3000
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RB0002X
TaxonomyObesity Medicine (Internal Medicine) Physician
License Number90000429
License Number StateMA
# 2
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number125-059970
License Number StateIL
# 3
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number258476
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: