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General NPI Number Information
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NPI Number | 1477618858
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Entity Type | Organization
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Legal Business Name | THOMAS A MOORE SR. MD A PROFESSIONAL MEDICAL CORPORATION
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Dates
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Enumeration Date | 12/26/2006
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 510 4TH ST S
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City | FARGO
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State | ND
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Zip | 58103-1914
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Country | US
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Telephone | 701-476-7200
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Fax |
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Provider Business Mailing Address
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Address Line | 1437 4TH ST N
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City | FARGO
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State | ND
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Zip | 58102-2732
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Country | US
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Telephone | 701-306-6126
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Fax |
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. THOMAS AQUINAS MOORE
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Credential | MD
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Telephone | 701-306-6126
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2084P0800X
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Taxonomy Name | Psychiatry Physician
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License Number | 7266
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License Number State | ND
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