Provider Demographics
NPI:1003816372
Name:MOORE, CHARLES A (MD)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:A
Last Name:MOORE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:PO BOX 309
Mailing Address - Street 2:
Mailing Address - City:MIDDLESBORO
Mailing Address - State:KY
Mailing Address - Zip Code:40965-0309
Mailing Address - Country:US
Mailing Address - Phone:606-248-0090
Mailing Address - Fax:606-248-8803
Practice Address - Street 1:123 N 19TH ST
Practice Address - Street 2:SUITE 201
Practice Address - City:MIDDLESBORO
Practice Address - State:KY
Practice Address - Zip Code:40965-2865
Practice Address - Country:US
Practice Address - Phone:606-248-0090
Practice Address - Fax:606-248-8803
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-28
Last Update Date:2010-04-27
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
KY22757207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY017423400OtherBLACK LUNG
KY1003816372Medicaid
VA000000251586OtherBLUE CROSS OF VA
KY1635649000OtherDEPARTMENT OF LABOR
TN000051203OtherBLUE CROSS OF TENNESSEE
KY000000062741OtherBLUE CROSS OF KY
KY110196198OtherRAIL ROAD MEDICARE
KY64227572Medicaid
KY1143OtherCHA
TN4176527OtherTENNESSE MEDICAID
KY1326780OtherUMWA
KY1659551935OtherMEDICARE GROUP NPI
VA006064205OtherVA MEDICAID
KY110196198OtherRAIL ROAD MEDICARE
KY1003816372Medicaid
KY1659551935Medicare NSC