Provider Demographics
NPI:1235416322
Name:BENJAMIN E MOORE MD PA
Entity Type:Organization
Organization Name:BENJAMIN E MOORE MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:BENJAMIN
Authorized Official - Middle Name:E
Authorized Official - Last Name:MOORE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:904-387-6116
Mailing Address - Street 1:PO BOX 17809
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32245-7809
Mailing Address - Country:US
Mailing Address - Phone:904-723-5665
Mailing Address - Fax:904-338-0951
Practice Address - Street 1:2 SHIRCLIFF WAY STE 925
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32204-4711
Practice Address - Country:US
Practice Address - Phone:904-387-6116
Practice Address - Fax:904-387-6118
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-11-03
Last Update Date:2012-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME393552084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLFP273AMedicare PIN