Provider Demographics
NPI:1760661367
Name:MATTHEW D MOORE LLC
Entity Type:Organization
Organization Name:MATTHEW D MOORE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MATTHEW
Authorized Official - Middle Name:D
Authorized Official - Last Name:MOORE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:937-429-9683
Mailing Address - Street 1:2141 NORTH FAIRFIELD ROAD
Mailing Address - Street 2:SUITE C
Mailing Address - City:BEAVERCREEK
Mailing Address - State:OH
Mailing Address - Zip Code:45431-2579
Mailing Address - Country:US
Mailing Address - Phone:937-429-9683
Mailing Address - Fax:937-429-9729
Practice Address - Street 1:2141 NORTH FAIRFIELD ROAD
Practice Address - Street 2:SUITE C
Practice Address - City:BEAVERCREEK
Practice Address - State:OH
Practice Address - Zip Code:45431-2579
Practice Address - Country:US
Practice Address - Phone:937-429-9683
Practice Address - Fax:937-429-9729
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-31
Last Update Date:2007-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35055799M207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH000000281392OtherANTHEM
OH0671983Medicaid
OH2060101OtherUHC
OH2060101OtherUHC