Provider Demographics
NPI:1720208242
Name:O FRED MOORE III MD PC
Entity Type:Organization
Organization Name:O FRED MOORE III MD PC
Other - Org Name:DRS JAMES A CAYLOR & O FRED MOORE III
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT OF CORPORATION
Authorized Official - Prefix:
Authorized Official - First Name:OLYN
Authorized Official - Middle Name:FRED
Authorized Official - Last Name:MOORE
Authorized Official - Suffix:III
Authorized Official - Credentials:MD
Authorized Official - Phone:731-285-5244
Mailing Address - Street 1:503 TICKLE STREET
Mailing Address - Street 2:
Mailing Address - City:DYERSBURG
Mailing Address - State:TN
Mailing Address - Zip Code:38024
Mailing Address - Country:US
Mailing Address - Phone:731-285-5244
Mailing Address - Fax:731-285-8970
Practice Address - Street 1:503 TICKLE STREET
Practice Address - Street 2:
Practice Address - City:DYERSBURG
Practice Address - State:TN
Practice Address - Zip Code:38024
Practice Address - Country:US
Practice Address - Phone:731-285-5244
Practice Address - Fax:731-285-5244
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-26
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3384206Medicaid
TN3384206Medicaid