Provider Demographics
NPI:1255433371
Name:MOORE, MICHELE (DO)
Entity type:Individual
Prefix:
First Name:MICHELE
Middle Name:
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 1:31249 WALKER RD
Mailing Address - Street 2:
Mailing Address - City:BAY VILLAGE
Mailing Address - State:OH
Mailing Address - Zip Code:44140-1409
Mailing Address - Country:US
Mailing Address - Phone:440-250-0635
Mailing Address - Fax:440-250-0635
Practice Address - Street 1:7575 NORTHCLIFF AVE
Practice Address - Street 2:SUITE 305
Practice Address - City:BROOKLYN
Practice Address - State:OH
Practice Address - Zip Code:44144-3267
Practice Address - Country:US
Practice Address - Phone:216-398-5535
Practice Address - Fax:216-749-3366
Is Sole Proprietor?:No
Enumeration Date:2006-09-01
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH34006836M207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH215841Medicaid
OH385235OtherANTHEM PIN NUMBER
OH7051201OtherAETNA PROVIDER NUMBER
OH743136652027Medicaid
OHH07639Medicare UPIN
OH743136652027Medicaid