MEDICARE: DR. KRISTIN EMILY MOORE MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	208000000X	Pediatrics Physician	19066	SC

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	570783896	OTHER	SC	FED TAX ID

General Provider Information

NPI Number	:	1154387801
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. KRISTIN EMILY MOORE MD

Provider Business Mailing Address
First Line	:	8120 ROURK ST
Second Line	:
City	:	MYRTLE BEACH
State	:	SC
Zip	:	29572-4127
Country	:	US
Telephone Number	:	843-449-1438
Fax Number	:	843-286-1349

Provider Business Practice Location Address
First Line	:	8120 ROURK ST
Second Line	:
City	:	MYRTLE BEACH
State	:	SC
Zip	:	29572-4127
Country	:	US
Telephone Number	:	843-449-1438
Fax Number	:	843-286-1349

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/21/2006
Last Update Date	:	07/29/2015

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