MEDICARE: PAUL DOUGLAS MOORE M.D.

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	207Q00000X	Family Medicine Physician	23342	SC

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	4591406	OTHER	SC	AETNA ID

General Provider Information

NPI Number	:	1194769661
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	PAUL DOUGLAS MOORE M.D.

Provider Business Mailing Address
First Line	:	1 INDEPENDENCE PT STE 212
Second Line	:
City	:	GREENVILLE
State	:	SC
Zip	:	29615-4536
Country	:	US
Telephone Number	:	864-797-6174
Fax Number	:

Provider Business Practice Location Address
First Line	:	910 N MAIN ST STE 100
Second Line	:
City	:	FOUNTAIN INN
State	:	SC
Zip	:	29644-1320
Country	:	US
Telephone Number	:	864-967-4982
Fax Number	:

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

Provider Enumeration Date	:	06/15/2006
Last Update Date	:	09/18/2024

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