Basic Information
| Provider Information | |||||||||
| NPI: | 1538381462 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MOORE | ||||||||
| FirstName: | AMY | ||||||||
| MiddleName: | MARCELLE | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 700 ACKERMAN RD STE 2120 | ||||||||
| Address2: | |||||||||
| City: | COLUMBUS | ||||||||
| State: | OH | ||||||||
| PostalCode: | 432021559 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6142938566 | ||||||||
| FaxNumber: | 6143660433 | ||||||||
| Practice Location | |||||||||
| Address1: | 915 OLENTANGY RIVER RD | ||||||||
| Address2: | |||||||||
| City: | COLUMBUS | ||||||||
| State: | OH | ||||||||
| PostalCode: | 432123153 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6142938566 | ||||||||
| FaxNumber: | 6142933381 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/02/2007 | ||||||||
| LastUpdateDate: | 03/01/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/01/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2082S0105X | 35138310 | OH | N | Allopathic & Osteopathic Physicians | Plastic Surgery | Surgery of the Hand | 2086S0105X | 2007030788 | MO | N | Allopathic & Osteopathic Physicians | Surgery | Surgery of the Hand | 2086S0122X | 2007030788 | MO | N | Allopathic & Osteopathic Physicians | Surgery | Plastic and Reconstructive Surgery | 208200000X | 35138310 | OH | Y | Allopathic & Osteopathic Physicians | Plastic Surgery |
ID Information
| ID | Type | State | Issuer | Description | H777590 | 01 | OH | MEDICARE-OSU PLASTIC SURGERY, LLC | OTHER | 0390307 | 05 | OH | MEDICAID | H777592 | 01 | OH | MEDICARE-CHILDREN'S SURGICAL ASSOCIATES, CORPORATION | OTHER | H777591 | 01 | OH | MEDICARE-OHIO STATE UNIVERSITY ORTHOPEDIC | OTHER |