Healthcare Provider Details

I. General information

NPI: 1407853047
Provider Name (Legal Business Name): KEVIN MOORE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/28/2005
Last Update Date: 02/02/2022
Certification Date: 02/02/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

401 MATTHEW ST
MARIETTA OH
45750-1635
US

IV. Provider business mailing address

11490 SPRINGFIELD PIKE
CINCINNATI OH
45246-3524
US

V. Phone/Fax

Practice location:
  • Phone: 740-568-5427
  • Fax: 740-376-5073
Mailing address:
  • Phone: 513-672-3309
  • Fax: 513-672-3323

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number35064203
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: