Healthcare Provider Details

I. General information

NPI: 1770849150
Provider Name (Legal Business Name): JOHN ALEXANDER MOORE D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/10/2012
Last Update Date: 11/01/2022
Certification Date: 11/01/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

274 E CHICAGO ST
COLDWATER MI
49036-2041
US

IV. Provider business mailing address

736 REEF DR
CANTON MI
48187-0106
US

V. Phone/Fax

Practice location:
  • Phone: 517-279-5400
  • Fax:
Mailing address:
  • Phone: 425-478-5160
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number5101019879
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: