MEDICARE: JORDAN A MOORE MD SC

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	207N00000X	Dermatology Physician

General Provider Information

NPI Number	:	1922322270
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	JORDAN A MOORE MD SC

Provider Business Mailing Address
First Line	:	121 E SILVER SPRING DR
Second Line	:
City	:	WHITEFISH BAY
State	:	WI
Zip	:	53217-4702
Country	:	US
Telephone Number	:	414-964-9030
Fax Number	:	414-964-9620

Provider Business Practice Location Address
First Line	:	121 E SILVER SPRING DR
Second Line	:
City	:	WHITEFISH BAY
State	:	WI
Zip	:	53217-4702
Country	:	US
Telephone Number	:	414-964-9030
Fax Number	:	414-964-9620

Authorized Official
Title or Position	:	PHYSICAN/OWNER
Name	:	DR. JORDAN A MOORE
Credential	:	M.D.
Telephone Number	:	414-964-9031

Provider Enumeration Date	:	03/16/2010
Last Update Date	:	03/16/2010

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