Provider Demographics
NPI:1619989696
Name:MOOREVILLE, MICHAEL (MD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:MOOREVILLE
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 1:272 N LANSDOWNE AVE
Mailing Address - Street 2:
Mailing Address - City:LANSDOWNE
Mailing Address - State:PA
Mailing Address - Zip Code:19050-1143
Mailing Address - Country:US
Mailing Address - Phone:610-259-3434
Mailing Address - Fax:610-259-3480
Practice Address - Street 1:272 N LANSDOWNE AVE
Practice Address - Street 2:
Practice Address - City:LANSDOWNE
Practice Address - State:PA
Practice Address - Zip Code:19050-1143
Practice Address - Country:US
Practice Address - Phone:610-259-3434
Practice Address - Fax:610-259-3480
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-11
Last Update Date:2008-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD022478E208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ4612083OtherAETNA
PA0009582890001Medicaid
PA4612083OtherAETNA
PA0031118000OtherIBC
PAB40496Medicare UPIN
PA4612083OtherAETNA
NJ486641Medicare PIN