Provider Demographics
NPI:1891973426
Name:MOORE, KERRY BRIGID (MD)
Entity Type:Individual
Prefix:DR
First Name:KERRY
Middle Name:BRIGID
Last Name:MOORE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:KERRY
Other - Middle Name:MOORE
Other - Last Name:SCRIVEN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:52 ANNANDALE RD
Mailing Address - Street 2:
Mailing Address - City:STONY BROOK
Mailing Address - State:NY
Mailing Address - Zip Code:11790-2410
Mailing Address - Country:US
Mailing Address - Phone:631-246-6220
Mailing Address - Fax:631-246-6220
Practice Address - Street 1:815 HALLOCK AVE
Practice Address - Street 2:SUITE A
Practice Address - City:PORT JEFFERSON STATION
Practice Address - State:NY
Practice Address - Zip Code:11776-1220
Practice Address - Country:US
Practice Address - Phone:631-331-7267
Practice Address - Fax:631-331-7267
Is Sole Proprietor?:Yes
Enumeration Date:2008-02-06
Last Update Date:2008-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY183552208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01500581Medicaid
NYF75023Medicare UPIN