Provider Demographics
NPI:1255214664
Name:MOORE, MEREDITH GRACE
Entity type:Individual
Prefix:
First Name:MEREDITH
Middle Name:GRACE
Last Name:MOORE
Suffix:
Gender:X
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10328 N LEELAND LN
Mailing Address - Street 2:
Mailing Address - City:SYRACUSE
Mailing Address - State:IN
Mailing Address - Zip Code:46567-9591
Mailing Address - Country:US
Mailing Address - Phone:248-463-0400
Mailing Address - Fax:
Practice Address - Street 1:340 W 10TH ST
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46202-3082
Practice Address - Country:US
Practice Address - Phone:317-274-8157
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-07-31
Last Update Date:2025-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program