Provider Demographics
NPI:1881688521
Name:MOORE, RICHARD A (PHD, MD)
Entity Type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:A
Last Name:MOORE
Suffix:
Gender:M
Credentials:PHD, MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:979 E 3RD ST
Mailing Address - Street 2:STE 300
Mailing Address - City:CHATTANOOGA
Mailing Address - State:TN
Mailing Address - Zip Code:37403-2136
Mailing Address - Country:US
Mailing Address - Phone:423-267-0466
Mailing Address - Fax:423-778-8168
Practice Address - Street 1:979 E 3RD ST
Practice Address - Street 2:STE 300
Practice Address - City:CHATTANOOGA
Practice Address - State:TN
Practice Address - Zip Code:37403-2136
Practice Address - Country:US
Practice Address - Phone:423-267-0466
Practice Address - Fax:423-778-8168
Is Sole Proprietor?:No
Enumeration Date:2005-09-08
Last Update Date:2019-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMD36974208600000X, 208C00000X, 208C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208C00000XAllopathic & Osteopathic PhysiciansColon & Rectal Surgery
No208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
1990242001OtherCIGNA
AL009915145Medicaid
280001172OtherRR MEDICARE
62165877478OtherJDH
TNQ002576Medicaid
GA00968899AMedicaid
4046885OtherBCBS OF TN
280001172OtherRR MEDICARE
GA00968899AMedicaid