Provider Demographics
NPI:1477618858
Name:THOMAS A MOORE SR. MD A PROFESSIONAL MEDICAL CORPORATION
Entity Type:Organization
Organization Name:THOMAS A MOORE SR. MD A PROFESSIONAL MEDICAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:AQUINAS
Authorized Official - Last Name:MOORE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:701-306-6126
Mailing Address - Street 1:1437 4TH ST N
Mailing Address - Street 2:
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58102-2732
Mailing Address - Country:US
Mailing Address - Phone:701-306-6126
Mailing Address - Fax:
Practice Address - Street 1:510 4TH ST S
Practice Address - Street 2:
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58103-1914
Practice Address - Country:US
Practice Address - Phone:701-476-7200
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-26
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND72662084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Single Specialty