Healthcare Provider Details

I. General information

NPI: 1467688507
Provider Name (Legal Business Name): VIRGINIA MARILYN MOORE M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/03/2009
Last Update Date: 06/03/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7550 TEAGUE RD 500
HANOVER MD
21076-1339
US

IV. Provider business mailing address

7550 TEAGUE RD 500
HANOVER MD
21076-1339
US

V. Phone/Fax

Practice location:
  • Phone: 410-981-4598
  • Fax: 410-981-4010
Mailing address:
  • Phone: 410-981-4598
  • Fax: 410-981-4010

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberD0056804
License Number StateMD
# 2
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number33844
License Number StateDC
# 3
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number0101229835
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: