Provider Demographics
NPI:1376738377
Name:MICHAEL MOORE, MD, PA
Entity Type:Organization
Organization Name:MICHAEL MOORE, MD, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:G
Authorized Official - Last Name:MOORE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:201-689-0110
Mailing Address - Street 1:171 FRANKLIN TPKE
Mailing Address - Street 2:SUITE 200
Mailing Address - City:WALDWICK
Mailing Address - State:NJ
Mailing Address - Zip Code:07463-1849
Mailing Address - Country:US
Mailing Address - Phone:201-689-0110
Mailing Address - Fax:201-689-0114
Practice Address - Street 1:171 FRANKLIN TPKE
Practice Address - Street 2:SUITE 200
Practice Address - City:WALDWICK
Practice Address - State:NJ
Practice Address - Zip Code:07463-1849
Practice Address - Country:US
Practice Address - Phone:201-689-0110
Practice Address - Fax:201-689-0114
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-12
Last Update Date:2012-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMA58638207X00000X
208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Multi-Specialty
No208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
097094Medicare PIN