Provider Demographics
NPI:1194031682
Name:ROBERT K MOORE MD PC
Entity Type:Organization
Organization Name:ROBERT K MOORE MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:K
Authorized Official - Last Name:MOORE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:586-436-5373
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
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-08-23
Last Update Date:2010-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301029450207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1666313Medicaid
MI0500002Medicare PIN
MI1666313Medicaid