Provider Demographics
NPI:1235165168
Name:MOORE, MICHAEL F (MD)
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:F
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 1:604 DIVISION ST
Mailing Address - Street 2:
Mailing Address - City:CLARKS SUMMIT
Mailing Address - State:PA
Mailing Address - Zip Code:18411-1928
Mailing Address - Country:US
Mailing Address - Phone:570-319-6933
Mailing Address - Fax:
Practice Address - Street 1:604 DIVISION ST
Practice Address - Street 2:
Practice Address - City:CLARKS SUMMIT
Practice Address - State:PA
Practice Address - Zip Code:18411-1928
Practice Address - Country:US
Practice Address - Phone:570-319-6933
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-23
Last Update Date:2016-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD022692E174400000X, 2086S0129X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular Surgery
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0007164390005Medicaid
PA0007164390005Medicaid
PAC30217Medicare UPIN