Provider Demographics
NPI:1578854576
Name:MOORE PRIMARY CARE
Entity Type:Organization
Organization Name:MOORE PRIMARY CARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PA-C
Authorized Official - Prefix:
Authorized Official - First Name:RANDALL
Authorized Official - Middle Name:
Authorized Official - Last Name:CARTER
Authorized Official - Suffix:
Authorized Official - Credentials:PA-C
Authorized Official - Phone:405-799-7400
Mailing Address - Street 1:1400 SE 4TH ST
Mailing Address - Street 2:SUITE H
Mailing Address - City:MOORE
Mailing Address - State:OK
Mailing Address - Zip Code:73160-7329
Mailing Address - Country:US
Mailing Address - Phone:405-799-7400
Mailing Address - Fax:405-799-7405
Practice Address - Street 1:1400 SE 4TH ST
Practice Address - Street 2:SUITE H
Practice Address - City:MOORE
Practice Address - State:OK
Practice Address - Zip Code:73160-7329
Practice Address - Country:US
Practice Address - Phone:405-799-7400
Practice Address - Fax:405-799-7405
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-04-25
Last Update Date:2011-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200079670AMedicaid