Provider Demographics
NPI:1558533760
Name:MOORE, J SUZANNE (MD)
Entity Type:Individual
Prefix:
First Name:J
Middle Name:SUZANNE
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:PO BOX 699
Mailing Address - Street 2:
Mailing Address - City:MOUNTAIN HOME
Mailing Address - State:TN
Mailing Address - Zip Code:37684-0699
Mailing Address - Country:US
Mailing Address - Phone:423-433-6039
Mailing Address - Fax:423-433-6060
Practice Address - Street 1:4 SHERIDAN SQ STE 200
Practice Address - Street 2:
Practice Address - City:KINGSPORT
Practice Address - State:TN
Practice Address - Zip Code:37660-7435
Practice Address - Country:US
Practice Address - Phone:423-246-7931
Practice Address - Fax:423-246-1906
Is Sole Proprietor?:No
Enumeration Date:2008-03-27
Last Update Date:2024-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARE-3235207RR0500X
TN43330207RR0500X, 207RR0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RR0500XAllopathic & Osteopathic PhysiciansInternal MedicineRheumatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNQ031247Medicaid
AR148195001Medicaid
AR5M205G717Medicare UPIN
TNQ031247Medicaid