=====================================================
General NPI Number Information
=====================================================
NPI Number | 1922217991
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JOHN C. MOORE M.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/22/2007
-----------------------------------------------------
Last Update Date | 11/17/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6525 FRANCE AVE S STE 200
-----------------------------------------------------
City | EDINA
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55435-2176
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 612-672-7422
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6525 FRANCE AVE S STE 200
-----------------------------------------------------
City | EDINA
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55435-2176
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 612-672-7422
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207RA0201X
-----------------------------------------------------
Taxonomy Name | Allergy & Immunology (Internal Medicine) Physician
-----------------------------------------------------
License Number | 61474
-----------------------------------------------------
License Number State | MN
-----------------------------------------------------