Provider Demographics
NPI:1689850794
Name:MOORE, KATHRYN ROSE (MD)
Entity Type:Individual
Prefix:DR
First Name:KATHRYN
Middle Name:ROSE
Last Name:MOORE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:KATHRYN
Other - Middle Name:ROSE
Other - Last Name:SHELL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:3931 LOUISIANA AVE S
Mailing Address - Street 2:
Mailing Address - City:ST LOUIS PARK
Mailing Address - State:MN
Mailing Address - Zip Code:55426-5000
Mailing Address - Country:US
Mailing Address - Phone:952-993-2750
Mailing Address - Fax:
Practice Address - Street 1:3931 LOUISIANA AVE S
Practice Address - Street 2:
Practice Address - City:ST LOUIS PARK
Practice Address - State:MN
Practice Address - Zip Code:55426-5000
Practice Address - Country:US
Practice Address - Phone:952-993-2750
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-01-18
Last Update Date:2014-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL125050108207R00000X
ORMD154557207RH0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine