Healthcare Provider Details

I. General information

NPI: 1477618858
Provider Name (Legal Business Name): THOMAS A MOORE SR. MD A PROFESSIONAL MEDICAL CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/26/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

510 4TH ST S
FARGO ND
58103-1914
US

IV. Provider business mailing address

1437 4TH ST N
FARGO ND
58102-2732
US

V. Phone/Fax

Practice location:
  • Phone: 701-476-7200
  • Fax:
Mailing address:
  • Phone: 701-306-6126
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number7266
License Number StateND

VIII. Authorized Official

Name: DR. THOMAS AQUINAS MOORE
Title or Position: PRESIDENT
Credential: MD
Phone: 701-306-6126