Provider Demographics
NPI:1144229246
Name:MOORE, PATRICIA A
Entity Type:Individual
Prefix:DR
First Name:PATRICIA
Middle Name:A
Last Name:MOORE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:52303 EMMONS RD
Mailing Address - Street 2:STE A7
Mailing Address - City:SOUTH BEND
Mailing Address - State:IN
Mailing Address - Zip Code:46637-4293
Mailing Address - Country:US
Mailing Address - Phone:574-277-5390
Mailing Address - Fax:574-277-6340
Practice Address - Street 1:52303 EMMONS RD
Practice Address - Street 2:STE A7
Practice Address - City:SOUTH BEND
Practice Address - State:IN
Practice Address - Zip Code:46637-4293
Practice Address - Country:US
Practice Address - Phone:574-277-5390
Practice Address - Fax:574-277-6340
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-20
Last Update Date:2017-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5901001129213E00000X
IN07000521A213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100223850AMedicaid
MI1470280Medicaid
MI1470280Medicaid
IN100223850AMedicaid
IN2552970001Medicare NSC
INT33928Medicare UPIN