Basic Information
| Provider Information | |||||||||
| NPI: | 1932216991 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MOORE | ||||||||
| FirstName: | KAY | ||||||||
| MiddleName: | L | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 74 POLO RD | ||||||||
| Address2: | |||||||||
| City: | COLUMBIA | ||||||||
| State: | SC | ||||||||
| PostalCode: | 292232806 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8037886146 | ||||||||
| FaxNumber: | 8034620312 | ||||||||
| Practice Location | |||||||||
| Address1: | 16 WOODCROSS DR | ||||||||
| Address2: | |||||||||
| City: | COLUMBIA | ||||||||
| State: | SC | ||||||||
| PostalCode: | 292122331 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8037320140 | ||||||||
| FaxNumber: | 8037324848 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/24/2006 | ||||||||
| LastUpdateDate: | 07/19/2011 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | 13663 | SC | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 136631 | 05 | SC | MEDICAID |