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NPI Code Detail

MEDICARE: MACKENZIE MOORE

MEDICARE: MACKENZIE MOORE
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
1390200000XStudent in an Organized Health Care Education/Training Program
2208600000XSurgery Physician66100MN

General Provider Information

NPI Number : 1629422993
Entity Type Code : Individual
Provider Name (Legal Business Name) : MACKENZIE MOORE
Provider Business Mailing Address
First Line : 2925 CHICAGO AVENUE
Second Line :
City : MINNEAPOLIS
State : MN
Zip : 55407-1321
Country : US
Telephone Number :
Fax Number :
Provider Business Practice Location Address
First Line : 920 E 28TH ST
Second Line : SUITE 460
City : MINNEAPOLIS
State : MN
Zip : 55407-1286
Country : US
Telephone Number : 612-863-7770
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 04/22/2016
Last Update Date : 09/07/2023

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Directions to “ MACKENZIE MOORE ” Practice Location

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These directions are for planning purposes only. You may find that construction projects, traffic, or other events may cause road conditions to differ from the map results.

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