Provider Demographics
NPI:1184671158
Name:MOORE, EDWARD E (MD)
Entity Type:Individual
Prefix:
First Name:EDWARD
Middle Name:E
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 1:1410 BLANDING ST
Mailing Address - Street 2:SUITE 205
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29201
Mailing Address - Country:US
Mailing Address - Phone:803-779-6320
Mailing Address - Fax:803-779-6323
Practice Address - Street 1:1410 BLANDING ST
Practice Address - Street 2:SUITE 205
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29201
Practice Address - Country:US
Practice Address - Phone:803-779-6320
Practice Address - Fax:803-779-6323
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC10002207VE0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VE0102XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyReproductive Endocrinology
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCG03136Medicaid
SC2667Medicare ID - Type Unspecified
D18224Medicare UPIN