Provider Demographics
NPI:1740209253
Name:MOORE, JR, CHARLES F (MD)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:F
Last Name:MOORE, JR
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 E LIBERTY ST
Mailing Address - Street 2:SUITE 800
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40202-1434
Mailing Address - Country:US
Mailing Address - Phone:502-367-3360
Mailing Address - Fax:502-367-3365
Practice Address - Street 1:727 HOSPITAL DR
Practice Address - Street 2:
Practice Address - City:SHELBYVILLE
Practice Address - State:KY
Practice Address - Zip Code:40065-1660
Practice Address - Country:US
Practice Address - Phone:502-367-3360
Practice Address - Fax:502-367-3365
Is Sole Proprietor?:No
Enumeration Date:2006-07-18
Last Update Date:2020-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY41169207R00000X, 207RR0500X
IN01056663A208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RR0500XAllopathic & Osteopathic PhysiciansInternal MedicineRheumatology
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000386253OtherBCBS - GATEWAY
KY64102056Medicaid
IN000000374581OtherBCBS - MARY STREET
INP00248435OtherRR MCARE PIN
IN200518340Medicaid
IN000000386253OtherBCBS - GATEWAY
I30470Medicare UPIN
IN639620AAAMedicare ID - Type Unspecified