Healthcare Provider Details

I. General information

NPI: 1093154254
Provider Name (Legal Business Name): NATHAN HERLING MOORE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/21/2013
Last Update Date: 02/15/2021
Certification Date: 02/15/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3009 N BALLAS RD STE 387C
SAINT LOUIS MO
63131-2322
US

IV. Provider business mailing address

3009 N BALLAS RD STE 387C
SAINT LOUIS MO
63131-2324
US

V. Phone/Fax

Practice location:
  • Phone: 314-996-5900
  • Fax: 314-996-5910
Mailing address:
  • Phone: 314-996-5900
  • Fax: 314-996-5910

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number2013018432
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number2015018622
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: