Healthcare Provider Details

I. General information

NPI: 1356361430
Provider Name (Legal Business Name): SUSAN J. MOORE M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/20/2006
Last Update Date: 11/14/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

112 CROFTON PLACE UVA LAKE MONTICELLO INTERNAL MEDICINE
PALMYRA VA
22963
US

IV. Provider business mailing address

PO BOX 9007
CHARLOTTESVILLE VA
22906-9007
US

V. Phone/Fax

Practice location:
  • Phone: 434-589-9030
  • Fax: 434-589-9040
Mailing address:
  • Phone: 434-295-1000
  • Fax: 434-972-4266

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number0101041674
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: