Provider Demographics
NPI:1396872636
Name:MOORE SURGICAL ASSOCIATES, P.C.
Entity type:Organization
Organization Name:MOORE SURGICAL ASSOCIATES, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:WAYNE
Authorized Official - Middle Name:E
Authorized Official - Last Name:MOORE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:219-362-8523
Mailing Address - Street 1:901 LINCOLNWAY
Mailing Address - Street 2:SUITE 304
Mailing Address - City:LA PORTE
Mailing Address - State:IN
Mailing Address - Zip Code:46350-3430
Mailing Address - Country:US
Mailing Address - Phone:219-362-8523
Mailing Address - Fax:219-324-9396
Practice Address - Street 1:901 LINCOLNWAY
Practice Address - Street 2:SUITE 304
Practice Address - City:LA PORTE
Practice Address - State:IN
Practice Address - Zip Code:46350-3430
Practice Address - Country:US
Practice Address - Phone:219-362-8523
Practice Address - Fax:219-324-9396
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-27
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN50000416208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty