Provider Demographics
NPI:1245282722
Name:MOORE, BRETT W (MD)
Entity type:Individual
Prefix:
First Name:BRETT
Middle Name:W
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 636799
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45263-0001
Mailing Address - Country:US
Mailing Address - Phone:513-569-5027
Mailing Address - Fax:513-569-5199
Practice Address - Street 1:10500 MONTGOMERY ROAD
Practice Address - Street 2:
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45242-4402
Practice Address - Country:US
Practice Address - Phone:513-865-2246
Practice Address - Fax:513-865-5596
Is Sole Proprietor?:No
Enumeration Date:2006-05-16
Last Update Date:2017-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35062552207P00000X
OH35.062552207R00000X, 208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2034926Medicaid
P00224123OtherRAIL ROAD MEDICARE
OH000000358968OtherBCBS
OH000000358968OtherBCBS
MO0734206Medicare PIN
OH2034926Medicaid
P00224123OtherRAIL ROAD MEDICARE