=====================================================
General NPI Number Information
=====================================================
NPI Number | 1720794167
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JOHN R MOORE APRN. CNP
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/30/2023
-----------------------------------------------------
Last Update Date | 01/30/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 718 N MACOMB ST
-----------------------------------------------------
City | MONROE
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48162-7815
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 419-708-8228
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 7012 CLOISTER RD
-----------------------------------------------------
City | TOLEDO
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 43617-2208
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 419-708-8228
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2084A0401X
-----------------------------------------------------
Taxonomy Name | Addiction Medicine (Psychiatry & Neurology) Physician
-----------------------------------------------------
License Number | 0032642
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 2084P0800X
-----------------------------------------------------
Taxonomy Name | Psychiatry Physician
-----------------------------------------------------
License Number | 0032642
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------