Provider Demographics
NPI:1871544916
Name:MOORE, MICHAEL M (MD)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:M
Last Name:MOORE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1331 E WYOMING AVE
Mailing Address - Street 2:MOB - LOWER LEVEL
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19124-3808
Mailing Address - Country:US
Mailing Address - Phone:215-831-1100
Mailing Address - Fax:215-807-8951
Practice Address - Street 1:1331 E WYOMING AVE
Practice Address - Street 2:MOB - LOWER LEVEL
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19124-3808
Practice Address - Country:US
Practice Address - Phone:215-831-1100
Practice Address - Fax:215-807-8951
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD-035365-E207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAE95741Medicare UPIN
PAM0486881Medicare ID - Type Unspecified