Provider Demographics
NPI:1871545061
Name:MOORE, KATHRYN L (MD)
Entity type:Individual
Prefix:
First Name:KATHRYN
Middle Name:L
Last Name:MOORE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 6069
Mailing Address - Street 2:
Mailing Address - City:WEST COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29171-6069
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:700 GERVAIS ST
Practice Address - Street 2:STE 300
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29201-3047
Practice Address - Country:US
Practice Address - Phone:803-254-3230
Practice Address - Fax:803-540-1180
Is Sole Proprietor?:No
Enumeration Date:2006-05-16
Last Update Date:2020-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC15776207VG0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VG0400XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCGP2294Medicaid
SCE64593Medicare UPIN
SC6129Medicare ID - Type Unspecified