Provider Demographics
NPI:1720049109
Name:MOORE, JASON L (MD)
Entity Type:Individual
Prefix:DR
First Name:JASON
Middle Name:L
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 1:27400 FRANKLIN RD
Mailing Address - Street 2:#B707
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48034-2358
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:45 10TH ST W
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55102-1062
Practice Address - Country:US
Practice Address - Phone:651-232-3000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-28
Last Update Date:2020-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN61613207P00000X
MI4301080458207P00000X, 207PE0004X
IA39945207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No207PE0004XAllopathic & Osteopathic PhysiciansEmergency MedicineEmergency Medical Services
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI104715823Medicaid
MI104785416Medicaid
MI104785425Medicaid
MIJM080458OtherBC/BS OF MI
MII28031Medicare UPIN
MIH26348335Medicare PIN