Healthcare Provider Details

I. General information

NPI: 1568552644
Provider Name (Legal Business Name): COURTENAY K MOORE MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/13/2006
Last Update Date: 04/02/2025
Certification Date: 04/02/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

915 OLENTANGY RIVER RD STE 2000
COLUMBUS OH
43212-3159
US

IV. Provider business mailing address

700 ACKERMAN RD STE 2120
COLUMBUS OH
43202-1559
US

V. Phone/Fax

Practice location:
  • Phone: 614-293-8155
  • Fax: 614-293-3565
Mailing address:
  • Phone: 614-293-8155
  • Fax: 614-293-3565

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208800000X
TaxonomyUrology Physician
License Number35085038
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code207VF0040X
TaxonomyUrogynecology and Reconstructive Pelvic Surgery (Obstetrics & Gynecology) Physician
License Number35085038
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: