Provider Demographics
NPI:1891736815
Name:MOORE, THOMAS B (MD)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:B
Last Name:MOORE
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 1:3020 SAINT JOHNS BLVD
Mailing Address - Street 2:STE A
Mailing Address - City:JOPLIN
Mailing Address - State:MO
Mailing Address - Zip Code:64804-1564
Mailing Address - Country:US
Mailing Address - Phone:417-781-5387
Mailing Address - Fax:417-781-7174
Practice Address - Street 1:3020 SAINT JOHNS BLVD
Practice Address - Street 2:STE A
Practice Address - City:JOPLIN
Practice Address - State:MO
Practice Address - Zip Code:64804-1564
Practice Address - Country:US
Practice Address - Phone:417-781-5387
Practice Address - Fax:417-781-7174
Is Sole Proprietor?:No
Enumeration Date:2006-06-09
Last Update Date:2012-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOR3B12207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS100164600EMedicaid
KSP00800249OtherRAIL ROAD MEDICARE
KS100164600FMedicaid
KS1891736815OtherBLUE CROSS OF KANSAS
MOP00800228OtherRAIL ROAD MEDICARE
MO201669439Medicaid
MO21620038OtherBLUE CROSS OF KANSAS CITY
KSKA1575028Medicare PIN
MOMA2083019Medicare PIN
KS100164600FMedicaid
MOMA2082019Medicare PIN