Provider Demographics
NPI:1730478744
Name:PHILIP A. MOORE, M.D., P.A.
Entity Type:Organization
Organization Name:PHILIP A. MOORE, M.D., P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:PHILIP
Authorized Official - Middle Name:ALAN
Authorized Official - Last Name:MOORE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:817-488-5170
Mailing Address - Street 1:1600 W COLLEGE ST
Mailing Address - Street 2:SUITE LL20
Mailing Address - City:GRAPEVINE
Mailing Address - State:TX
Mailing Address - Zip Code:76051-3580
Mailing Address - Country:US
Mailing Address - Phone:817-488-5170
Mailing Address - Fax:817-488-6270
Practice Address - Street 1:1600 W COLLEGE ST
Practice Address - Street 2:SUITE LL20
Practice Address - City:GRAPEVINE
Practice Address - State:TX
Practice Address - Zip Code:76051-3580
Practice Address - Country:US
Practice Address - Phone:817-488-5170
Practice Address - Fax:817-488-6270
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-03-30
Last Update Date:2011-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXF1835208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX0362543Medicaid
TX0362543Medicaid
TY79Medicare PIN