Provider Demographics
NPI:1205942075
Name:MOORE, BRIAN G (MD)
Entity type:Individual
Prefix:
First Name:BRIAN
Middle Name:G
Last Name:MOORE
Suffix:
Gender:M
Credentials:MD
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 781076
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48278-1076
Mailing Address - Country:US
Mailing Address - Phone:317-528-4800
Mailing Address - Fax:317-865-1479
Practice Address - Street 1:900 I ST FL 2
Practice Address - Street 2:
Practice Address - City:LA PORTE
Practice Address - State:IN
Practice Address - Zip Code:46350-5533
Practice Address - Country:US
Practice Address - Phone:219-575-6060
Practice Address - Fax:219-575-6004
Is Sole Proprietor?:No
Enumeration Date:2006-08-22
Last Update Date:2024-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01040502A208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200086240AMedicaid
01040502BOtherCSR
INBM3307875OtherDEA
IN200086240AMedicaid
WI333407020OtherSTATE LICENSE
01040502BOtherCSR
IN484020CMedicare ID - Type Unspecified