Healthcare Provider Details

I. General information

NPI: 1457433856
Provider Name (Legal Business Name): RUSSELL RAY MOORES JR. M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/19/2006
Last Update Date: 09/28/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1250 E MARSHALL STREET PEDIATRICS
RICHMOND VA
23298-0510
US

IV. Provider business mailing address

PO BOX 91734
RICHMOND VA
23291-1734
US

V. Phone/Fax

Practice location:
  • Phone: 804-828-9602
  • Fax: 804-828-8517
Mailing address:
  • Phone: 804-358-6100
  • Fax: 804-342-7619

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2080N0001X
TaxonomyNeonatal-Perinatal Medicine Physician
License NumberD41551
License Number StateMD
# 2
Primary TaxonomyY
Taxonomy Code2080N0001X
TaxonomyNeonatal-Perinatal Medicine Physician
License Number0101245140
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: