Provider Demographics
NPI:1093743965
Name:MOORE, RICHARD HENNING (MD)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:HENNING
Last Name:MOORE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:406 ALGONQUIN CT
Mailing Address - Street 2:
Mailing Address - City:BLACKSBURG
Mailing Address - State:VA
Mailing Address - Zip Code:24060-7871
Mailing Address - Country:US
Mailing Address - Phone:540-392-5222
Mailing Address - Fax:
Practice Address - Street 1:200 HOSPITAL DR
Practice Address - Street 2:
Practice Address - City:GALAX
Practice Address - State:VA
Practice Address - Zip Code:24333-2227
Practice Address - Country:US
Practice Address - Phone:276-236-8181
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-29
Last Update Date:2015-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101037610207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
B06318Medicare UPIN