Provider Demographics
NPI:1285681445
Name:MOORE, ELLEN CECILE (MD)
Entity Type:Individual
Prefix:
First Name:ELLEN
Middle Name:CECILE
Last Name:MOORE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14 WOODRIDGE DR
Mailing Address - Street 2:
Mailing Address - City:GREENBRIER
Mailing Address - State:AR
Mailing Address - Zip Code:72058-9583
Mailing Address - Country:US
Mailing Address - Phone:248-549-0861
Mailing Address - Fax:
Practice Address - Street 1:14 WOODRIDGE DR
Practice Address - Street 2:
Practice Address - City:GREENBRIER
Practice Address - State:AR
Practice Address - Zip Code:72058-9583
Practice Address - Country:US
Practice Address - Phone:248-549-0861
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-30
Last Update Date:2016-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301038528208000000X
ARE-6324208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics