=====================================================
General NPI Number Information
=====================================================
NPI Number | 1497887905
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | GEOFFREY E. MOORE, M.D., P.C.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/10/2007
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 310 TAUGHANNOCK BLVD SUITE 5B
-----------------------------------------------------
City | ITHACA
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 14850-3231
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 607-257-5990
-----------------------------------------------------
Fax | 607-257-5973
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 310 TAUGHANNOCK BLVD SUITE 5B
-----------------------------------------------------
City | ITHACA
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 14850-3231
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 607-257-5990
-----------------------------------------------------
Fax | 607-257-5973
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. GEOFFREY E MOORE
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 607-257-5990
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207RS0010X
-----------------------------------------------------
Taxonomy Name | Sports Medicine (Internal Medicine) Physician
-----------------------------------------------------
License Number | 227508-01
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------