=====================================================
General NPI Number Information
=====================================================
NPI Number | 1740402999
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CHARLES H MOOREFIELD III MD PA
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/03/2007
-----------------------------------------------------
Last Update Date | 07/13/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 701 E MICHIGAN ST
-----------------------------------------------------
City | ORLANDO
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32806-4623
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 407-843-8300
-----------------------------------------------------
Fax | 407-843-6103
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 701 E MICHIGAN ST
-----------------------------------------------------
City | ORLANDO
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32806-4623
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 407-843-8300
-----------------------------------------------------
Fax | 407-843-6103
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | CHARLES H MOOREFIELD III
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 407-843-8300
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208D00000X
-----------------------------------------------------
Taxonomy Name | General Practice Physician
-----------------------------------------------------
License Number | 0040364
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------