Healthcare Provider Details

I. General information

NPI: 1134370646
Provider Name (Legal Business Name): COLIN MOORE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/02/2008
Last Update Date: 12/06/2022
Certification Date: 12/06/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2525 CHICAGO AVE
MINNEAPOLIS MN
55404-4518
US

IV. Provider business mailing address

2525 CHICAGO AVE
MINNEAPOLIS MN
55404-4518
US

V. Phone/Fax

Practice location:
  • Phone: 612-813-7393
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080P0207X
TaxonomyPediatric Hematology & Oncology Physician
License NumberME 117056
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: