Provider Demographics
NPI:1336302280
Name:MOORE, MICHAEL R (MD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:R
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:PO BOX 157
Mailing Address - Street 2:
Mailing Address - City:ELLINGTON
Mailing Address - State:MO
Mailing Address - Zip Code:63638-0157
Mailing Address - Country:US
Mailing Address - Phone:573-663-2313
Mailing Address - Fax:573-663-2322
Practice Address - Street 1:1003 SOUTH MAIN STREET
Practice Address - Street 2:
Practice Address - City:EMININCE
Practice Address - State:MO
Practice Address - Zip Code:65466-0100
Practice Address - Country:US
Practice Address - Phone:573-226-5505
Practice Address - Fax:573-226-5584
Is Sole Proprietor?:No
Enumeration Date:2008-07-09
Last Update Date:2012-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOR4837207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO1336302280Medicaid
MO1285957001OtherMEDICAID (GROUP)
MO26D2006074OtherCLIA
MO597780303OtherRH MEDICAID
D04801Medicare UPIN
MO261841Medicare Oscar/Certification
MO26D2006074OtherCLIA
MO1336302280Medicaid
MOMA2517001Medicare PIN
MO121690001Medicare PIN