Provider Demographics
NPI:1740289065
Name:MOORE, TED (MD)
Entity type:Individual
Prefix:
First Name:TED
Middle Name:
Last Name:MOORE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1700 RING RD
Mailing Address - Street 2:
Mailing Address - City:ELIZABETHTOWN
Mailing Address - State:KY
Mailing Address - Zip Code:42701-9497
Mailing Address - Country:US
Mailing Address - Phone:270-769-5551
Mailing Address - Fax:270-765-3919
Practice Address - Street 1:1700 RING RD
Practice Address - Street 2:
Practice Address - City:ELIZABETHTOWN
Practice Address - State:KY
Practice Address - Zip Code:42701-9497
Practice Address - Country:US
Practice Address - Phone:270-769-5551
Practice Address - Fax:270-765-3919
Is Sole Proprietor?:No
Enumeration Date:2005-07-19
Last Update Date:2008-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY24016208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY000000045856OtherANTHEM BCBS
KY64240161Medicaid
KY1048776OtherPASSPORT
KY000000045856OtherANTHEM BCBS
KY64240161Medicaid