Provider Demographics
NPI:1780661207
Name:MOORE, GREGORY W (MD)
Entity Type:Individual
Prefix:DR
First Name:GREGORY
Middle Name:W
Last Name:MOORE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 3407
Mailing Address - Street 2:
Mailing Address - City:EVANSVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:47733-3407
Mailing Address - Country:US
Mailing Address - Phone:812-450-6815
Mailing Address - Fax:812-450-6822
Practice Address - Street 1:600 MARY ST
Practice Address - Street 2:
Practice Address - City:EVANSVILLE
Practice Address - State:IN
Practice Address - Zip Code:47747-0001
Practice Address - Country:US
Practice Address - Phone:812-450-3405
Practice Address - Fax:812-450-3099
Is Sole Proprietor?:No
Enumeration Date:2005-12-27
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01039918A207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64221641Medicaid
IN000000378774OtherBCBS - DEACONESS PIN
IN534980CCCMedicare ID - Type UnspecifiedDEACONESS PIN
KY64221641Medicaid
INP00281553Medicare PIN