Provider Demographics
NPI:1154302784
Name:MOORE, KEITH S (MD)
Entity Type:Individual
Prefix:
First Name:KEITH
Middle Name:S
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 1:1100 JOHNSON FY RD NE
Mailing Address - Street 2:SUITE 165
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30342-1709
Mailing Address - Country:US
Mailing Address - Phone:404-446-2800
Mailing Address - Fax:404-446-2809
Practice Address - Street 1:1100 JOHNSON FY RD NE
Practice Address - Street 2:SUITE 165
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30342-1709
Practice Address - Country:US
Practice Address - Phone:404-446-2800
Practice Address - Fax:404-446-2809
Is Sole Proprietor?:No
Enumeration Date:2005-11-10
Last Update Date:2016-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXM8850208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX195354901Medicaid
TX8G6219OtherBC/BS TX#
TXP00614620OtherRAILROAD MEDICARE
TX8K5901Medicare PIN
TX195354901Medicaid