Provider Demographics
NPI:1669508396
Name:CHARLES H MOORE, MD PA
Entity Type:Organization
Organization Name:CHARLES H MOORE, MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:H
Authorized Official - Last Name:MOORE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:361-884-0033
Mailing Address - Street 1:613 ELIZABETH ST
Mailing Address - Street 2:SUITE 511
Mailing Address - City:CORPUS CHRISTI
Mailing Address - State:TX
Mailing Address - Zip Code:78404-2220
Mailing Address - Country:US
Mailing Address - Phone:361-884-0033
Mailing Address - Fax:
Practice Address - Street 1:613 ELIZABETH ST
Practice Address - Street 2:SUITE 511
Practice Address - City:CORPUS CHRISTI
Practice Address - State:TX
Practice Address - Zip Code:78404-2220
Practice Address - Country:US
Practice Address - Phone:361-884-0033
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-26
Last Update Date:2008-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXD1744204F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes204F00000XAllopathic & Osteopathic PhysiciansTransplant SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX0058MHOtherBCBS
TX115054205Medicaid
TXD67436Medicare UPIN
TX0058MHOtherBCBS