Provider Demographics
NPI:1992785018
Name:MOORE, STEPHEN LEE (DO)
Entity type:Individual
Prefix:DR
First Name:STEPHEN
Middle Name:LEE
Last Name:MOORE
Suffix:
Gender:M
Credentials:DO
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 23229
Mailing Address - Street 2:
Mailing Address - City:OWENSBORO
Mailing Address - State:KY
Mailing Address - Zip Code:42304-3229
Mailing Address - Country:US
Mailing Address - Phone:270-688-1330
Mailing Address - Fax:270-688-1338
Practice Address - Street 1:1301 PLEASANT VALLEY RD
Practice Address - Street 2:SUITE 202
Practice Address - City:OWENSBORO
Practice Address - State:KY
Practice Address - Zip Code:42303-9774
Practice Address - Country:US
Practice Address - Phone:270-417-7500
Practice Address - Fax:270-417-7509
Is Sole Proprietor?:No
Enumeration Date:2006-01-17
Last Update Date:2016-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH34004442207RC0000X, 207RC0001X
KY03919207RC0000X, 207RC0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0001XAllopathic & Osteopathic PhysiciansInternal MedicineClinical Cardiac Electrophysiology
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN201336910Medicaid
KY7100373990Medicaid
OH0684531Medicaid
OHMO0614865Medicare PIN
FLBJ129ZMedicare PIN
KYK194710Medicare PIN
OH0684531Medicaid
OH000000128701OtherANTHEM
FLBJ129ZMedicare PIN
060017586OtherRAILROAD MEDICARE
OH100407OtherKAISER
OH0684531Medicaid
FLP00681780OtherRAIL ROAD MEDICARE