Provider Demographics
NPI:1659327443
Name:MOORE, GRAHAM J (MD)
Entity Type:Individual
Prefix:
First Name:GRAHAM
Middle Name:J
Last Name:MOORE
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 1:140 HOSPITAL DR
Mailing Address - Street 2:SUITE 203
Mailing Address - City:BENNINGTON
Mailing Address - State:VT
Mailing Address - Zip Code:05201-5009
Mailing Address - Country:US
Mailing Address - Phone:802-442-3800
Mailing Address - Fax:802-442-3855
Practice Address - Street 1:140 HOSPITAL DR
Practice Address - Street 2:SUITE 203
Practice Address - City:BENNINGTON
Practice Address - State:VT
Practice Address - Zip Code:05201-5009
Practice Address - Country:US
Practice Address - Phone:802-442-3800
Practice Address - Fax:802-442-3855
Is Sole Proprietor?:No
Enumeration Date:2006-05-25
Last Update Date:2008-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD0060214208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA2139979Medicaid
VT1013995Medicaid
I56726Medicare UPIN
MA000177201Medicare PIN