Provider Demographics
NPI:1659737120
Name:RICHARD E MOORE MEDICAL PA
Entity Type:Organization
Organization Name:RICHARD E MOORE MEDICAL PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE ADMIN
Authorized Official - Prefix:MRS
Authorized Official - First Name:TRYSTA
Authorized Official - Middle Name:
Authorized Official - Last Name:MCGUIRE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:501-733-0311
Mailing Address - Street 1:523 HARKRIDER ST
Mailing Address - Street 2:
Mailing Address - City:CONWAY
Mailing Address - State:AR
Mailing Address - Zip Code:72032-5631
Mailing Address - Country:US
Mailing Address - Phone:501-327-4484
Mailing Address - Fax:501-327-5963
Practice Address - Street 1:523 HARKRIDER ST
Practice Address - Street 2:
Practice Address - City:CONWAY
Practice Address - State:AR
Practice Address - Zip Code:72032-5631
Practice Address - Country:US
Practice Address - Phone:501-327-4484
Practice Address - Fax:501-327-5963
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-01-13
Last Update Date:2016-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARMC-3139207L00000X, 207LP2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiologyGroup - Single Specialty
No207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ARMC-3139OtherAR STATE MEDICAL BOARD LICENSE NUMBER