MEDICARE: JON MOORE AGEE 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	208600000X	Surgery Physician	M-5972	ID

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	000010004422	OTHER	ID	REGENCE BLUE SHIELD
3	59725	OTHER	ID	BLUE CROSS OF IDAHO

General Provider Information

NPI Number	:	1710941026
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JON MOORE AGEE M.D.

Provider Business Mailing Address
First Line	:	PO BOX 742941
Second Line	:
City	:	ATLANTA
State	:	GA
Zip	:	30374-2941
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	404 E ELM ST
Second Line	:
City	:	CALDWELL
State	:	ID
Zip	:	83605-4846
Country	:	US
Telephone Number	:	208-459-0028
Fax Number	:	208-459-0380

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

Provider Enumeration Date	:	04/13/2006
Last Update Date	:	01/25/2022

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