Provider Demographics
NPI:1235132978
Name:MOORE, MICHAEL ROY (MD)
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:ROY
Last Name:MOORE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:MICHAEL
Other - Middle Name:ROY
Other - Last Name:MOORE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:2800 10TH AVE N
Mailing Address - Street 2:
Mailing Address - City:BILLINGS
Mailing Address - State:MT
Mailing Address - Zip Code:59101-0703
Mailing Address - Country:US
Mailing Address - Phone:406-238-2759
Mailing Address - Fax:406-238-2723
Practice Address - Street 1:301 W POPLAR ST STE 210
Practice Address - Street 2:
Practice Address - City:WALLA WALLA
Practice Address - State:WA
Practice Address - Zip Code:99362-2800
Practice Address - Country:US
Practice Address - Phone:509-897-5788
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-05-25
Last Update Date:2023-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO330952081P2900X
CAG85748225400000X
WAMD613241522081P2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2081P2900XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationPain Medicine
No225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G857480Medicaid
CA00G857480Medicare ID - Type UnspecifiedMEDICARE
CA00G857480Medicaid