Provider Demographics
NPI:1144219684
Name:MOORE, ROBERT K (MD)
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:K
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 1:28341 HOOVER RD
Mailing Address - Street 2:
Mailing Address - City:WARREN
Mailing Address - State:MI
Mailing Address - Zip Code:48093-4151
Mailing Address - Country:US
Mailing Address - Phone:586-751-8890
Mailing Address - Fax:586-751-1103
Practice Address - Street 1:28341 HOOVER RD
Practice Address - Street 2:
Practice Address - City:WARREN
Practice Address - State:MI
Practice Address - Zip Code:48093-4151
Practice Address - Country:US
Practice Address - Phone:586-751-8890
Practice Address - Fax:586-751-1103
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-18
Last Update Date:2010-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301029450207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1666313Medicaid
MI0500002OtherBLUE CROSS/BLUE SHIELD
A74055Medicare UPIN
MI0500002OtherBLUE CROSS/BLUE SHIELD