Provider Demographics
NPI:1134116106
Name:MOORE, LINDA J (MD)
Entity Type:Individual
Prefix:DR
First Name:LINDA
Middle Name:J
Last Name:MOORE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:LINDA
Other - Middle Name:JILL
Other - Last Name:KOSOBUCKI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:850 BROOKSTONE CENTRE PKWY STE 200
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:GA
Mailing Address - Zip Code:31904-9245
Mailing Address - Country:US
Mailing Address - Phone:706-507-4242
Mailing Address - Fax:
Practice Address - Street 1:850 BROOKSTONE CENTRE PKWY STE 200
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:GA
Practice Address - Zip Code:31904-9245
Practice Address - Country:US
Practice Address - Phone:706-507-4242
Practice Address - Fax:706-507-4227
Is Sole Proprietor?:No
Enumeration Date:2005-10-04
Last Update Date:2024-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA055849207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA420338399AMedicaid
GAP01353083OtherRAILROAD MEDICARE
GA202I081211OtherMEDICARE PTAN
GA420338399EMedicaid
GA420338399AMedicaid
GA08BBBRTPMedicare PIN
GAP01353083OtherRAILROAD MEDICARE