MEDICARE: DR. MICHAEL ROY 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	2081P2900X	Pain Medicine (Physical Medicine & Rehabilitation) Physician	33095	CO
2	2081P2900X	Pain Medicine (Physical Medicine & Rehabilitation) Physician	MD61324152	WA
3	225400000X	Rehabilitation Practitioner	G85748	CA
4	208100000X	Physical Medicine & Rehabilitation Physician	MD61324152	WA

General Provider Information

NPI Number	:	1235132978
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MICHAEL ROY MOORE M.D.

Provider Business Mailing Address
First Line	:	301 W POPLAR ST
Second Line	:
City	:	WALLA WALLA
State	:	WA
Zip	:	99362-2858
Country	:	US
Telephone Number	:	95-897-8959
Fax Number	:	95-897-5788

Provider Business Practice Location Address
First Line	:	301 W POPLAR ST STE 210
Second Line	:
City	:	WALLA WALLA
State	:	WA
Zip	:	99362-2800
Country	:	US
Telephone Number	:	509-897-5788
Fax Number	:

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

Provider Enumeration Date	:	05/25/2005
Last Update Date	:	05/27/2025

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