Basic Information
| Provider Information | |||||||||
| NPI: | 1689655151 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MOORE | ||||||||
| FirstName: | MICHAEL | ||||||||
| MiddleName: | J | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 9132 | ||||||||
| Address2: | |||||||||
| City: | BROOKLINE | ||||||||
| State: | MA | ||||||||
| PostalCode: | 024469132 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8009270002 | ||||||||
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| Practice Location | |||||||||
| Address1: | 131 ORNAC | ||||||||
| Address2: | JOHN CUMMINGS BLDG | ||||||||
| City: | CONCORD | ||||||||
| State: | MA | ||||||||
| PostalCode: | 017424181 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7812590803 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/10/2005 | ||||||||
| LastUpdateDate: | 09/27/2012 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | 29410 | MA | N | Other Service Providers | Specialist | 2084N0400X | 29410 | MA | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology |
ID Information
| ID | Type | State | Issuer | Description | B23053 | 01 | MA | BCBS | OTHER | 029410 | 01 | MA | TUFTS | OTHER | 11461 | 01 | MA | HARVARD PILGRIM | OTHER | 000000024368 | 01 | MA | BMC HEALTHNET | OTHER | 3196640 | 05 | MA | MEDICAID | 05-04349 | 01 | MA | UNITED HEALTHCARE | OTHER |