Healthcare Provider Details

I. General information

NPI: 1306888300
Provider Name (Legal Business Name): GARY ARLAN MOORE MD, FAAFP, FACEP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/12/2006
Last Update Date: 11/30/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1508 TOMBRAS AVE
EAST RIDGE TN
37412
US

IV. Provider business mailing address

1508 TOMBRAS AVE
EAST RIDGE TN
37412-2720
US

V. Phone/Fax

Practice location:
  • Phone: 423-867-4969
  • Fax: 423-867-4971
Mailing address:
  • Phone: 423-867-4969
  • Fax: 423-867-4971

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number29619
License Number StateTN
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number29619
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: