Healthcare Provider Details

I. General information

NPI: 1053437079
Provider Name (Legal Business Name): ETHEL LAMAR MOORE M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/21/2007
Last Update Date: 02/01/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

RR 1 BOX 67
HARLEM MT
59526-9705
US

IV. Provider business mailing address

RR 1 BOX 77
HARLEM MT
59526-9706
US

V. Phone/Fax

Practice location:
  • Phone: 406-353-3100
  • Fax: 406-353-3229
Mailing address:
  • Phone: 406-353-3137
  • Fax: 406-353-3229

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberC 6449
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: