Provider Demographics
NPI:1124221247
Name:RICHARD E. MOORE, M.D.
Entity Type:Organization
Organization Name:RICHARD E. MOORE, M.D.
Other - Org Name:ADA ORTHOPAEDIC CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:M.D.
Authorized Official - Prefix:DR
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:
Authorized Official - Last Name:MOORE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:208-377-0777
Mailing Address - Street 1:6500 W EMERALD ST
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83704-8736
Mailing Address - Country:US
Mailing Address - Phone:208-377-0777
Mailing Address - Fax:208-377-1070
Practice Address - Street 1:6500 W EMERALD ST
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83704-8736
Practice Address - Country:US
Practice Address - Phone:208-377-0777
Practice Address - Fax:208-377-1070
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-06
Last Update Date:2010-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM5456207X00000X
IDM8524207X00000X
IDPA370363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Single Specialty
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1370500Medicare ID - Type UnspecifiedMEDICARE GROUP NUMBER
ID0347440001Medicare NSC