Provider Demographics
NPI:1194705269
Name:MOORE, ANN MARGARET (DO)
Entity type:Individual
Prefix:DR
First Name:ANN
Middle Name:MARGARET
Last Name:MOORE
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:800 BROADWAY
Mailing Address - Street 2:SUITE 115
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46802-2149
Mailing Address - Country:US
Mailing Address - Phone:260-425-3636
Mailing Address - Fax:
Practice Address - Street 1:800 BROADWAY
Practice Address - Street 2:SUITE 115
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46802-2149
Practice Address - Country:US
Practice Address - Phone:260-425-3636
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-01-17
Last Update Date:2011-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN02002191A207RG0300X, 207RH0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric Medicine
No207RH0002XAllopathic & Osteopathic PhysiciansInternal MedicineHospice and Palliative Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000283793OtherANTHEM
IN200290130Medicaid
IN000000283793OtherANTHEM
INH26005Medicare UPIN
IN150640JJJMedicare PIN
IN200290130Medicaid