MEDICARE: MICHAEL M. 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	MD-035365-E	PA

General Provider Information

NPI Number	:	1871544916
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MICHAEL M. MOORE M.D.

Provider Business Mailing Address
First Line	:	1331 E WYOMING AVE
Second Line	:	MOB - LOWER LEVEL
City	:	PHILADELPHIA
State	:	PA
Zip	:	19124-3808
Country	:	US
Telephone Number	:	215-831-1100
Fax Number	:	215-807-8951

Provider Business Practice Location Address
First Line	:	1331 E WYOMING AVE
Second Line	:	MOB - LOWER LEVEL
City	:	PHILADELPHIA
State	:	PA
Zip	:	19124-3808
Country	:	US
Telephone Number	:	215-831-1100
Fax Number	:	215-807-8951

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

Provider Enumeration Date	:	05/13/2006
Last Update Date	:	07/08/2007

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