Healthcare Provider Details

I. General information

NPI: 1982655312
Provider Name (Legal Business Name): CHARLES R MOORE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 05/12/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1000 E 1ST ST STE 203
DULUTH MN
55805-2297
US

IV. Provider business mailing address

1000 E 1ST ST STE 203
DULUTH MN
55805-2297
US

V. Phone/Fax

Practice location:
  • Phone: 218-249-6960
  • Fax:
Mailing address:
  • Phone: 218-249-6960
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RR0500X
TaxonomyRheumatology Physician
License Number42339
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: