Provider Demographics
NPI:1851329429
Name:MOE, TERRANCE D (MD)
Entity Type:Individual
Prefix:
First Name:TERRANCE
Middle Name:D
Last Name:MOE
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 1:150 HOSPITAL RD
Mailing Address - Street 2:
Mailing Address - City:EAGLE RIVER
Mailing Address - State:WI
Mailing Address - Zip Code:54521-8877
Mailing Address - Country:US
Mailing Address - Phone:715-479-8887
Mailing Address - Fax:
Practice Address - Street 1:150 HOSPITAL RD
Practice Address - Street 2:
Practice Address - City:EAGLE RIVER
Practice Address - State:WI
Practice Address - Zip Code:54521-8877
Practice Address - Country:US
Practice Address - Phone:715-479-8887
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-30
Last Update Date:2008-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI30319-020207P00000X, 208600000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No208600000XAllopathic & Osteopathic PhysiciansSurgery
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI31593800Medicaid
WI31593800Medicaid
WI0027-00508Medicare ID - Type UnspecifiedMEDICARE PART B