Healthcare Provider Details

I. General information

NPI: 1326096470
Provider Name (Legal Business Name): KENNETH EDWARD MOORE M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 05/04/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

MCGUIRE VAMC 1201 BROAD ROCK RD
RICHMOND VA
23249
US

IV. Provider business mailing address

10064 BEECHWOOD DR
MECHANICSVILLE VA
23116-2730
US

V. Phone/Fax

Practice location:
  • Phone: 804-675-5027
  • Fax:
Mailing address:
  • Phone: 804-730-7898
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2081P0004X
TaxonomySpinal Cord Injury Medicine Physician
License Number0101045616
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: