Healthcare Provider Details

I. General information

NPI: 1760677827
Provider Name (Legal Business Name): CHARLES SIDNEY MOORE JR. CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/12/2007
Last Update Date: 11/06/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2851 BAGLYOS CIR STE 100
BETHLEHEM PA
18020
US

IV. Provider business mailing address

5100 W TILGHMAN ST STE 315
ALLENTOWN PA
18104-9166
US

V. Phone/Fax

Practice location:
  • Phone: 484-821-0550
  • Fax: 484-821-0559
Mailing address:
  • Phone: 610-395-4044
  • Fax: 610-395-5693

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberRN538686
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: