Healthcare Provider Details

I. General information

NPI: 1871544916
Provider Name (Legal Business Name): MICHAEL M. MOORE M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 05/13/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1331 E WYOMING AVE MOB - LOWER LEVEL
PHILADELPHIA PA
19124-3808
US

IV. Provider business mailing address

1331 E WYOMING AVE MOB - LOWER LEVEL
PHILADELPHIA PA
19124-3808
US

V. Phone/Fax

Practice location:
  • Phone: 215-831-1100
  • Fax: 215-807-8951
Mailing address:
  • Phone: 215-831-1100
  • Fax: 215-807-8951

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberMD-035365-E
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: