Provider Demographics
NPI:1164443529
Name:MOORE, JACK C II (MD)
Entity Type:Individual
Prefix:
First Name:JACK
Middle Name:C
Last Name:MOORE
Suffix:II
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 1:100 E LIBERTY ST STE 800
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40202-1428
Mailing Address - Country:US
Mailing Address - Phone:502-244-0911
Mailing Address - Fax:502-253-0581
Practice Address - Street 1:175 S ENGLISH STATION RD STE 226
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40245
Practice Address - Country:US
Practice Address - Phone:502-244-0911
Practice Address - Fax:502-253-0581
Is Sole Proprietor?:No
Enumeration Date:2006-07-21
Last Update Date:2019-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY34365207Q00000X
IN01069727A207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KYP01073440OtherMEDICARE RAILROAD
KY64040173Medicaid
KYF08798Medicare UPIN
KYK049840Medicare PIN