Provider Demographics
NPI:1396735577
Name:MOORE, GLENN I (MD)
Entity type:Individual
Prefix:MR
First Name:GLENN
Middle Name:I
Last Name:MOORE
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Gender:M
Credentials:MD
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Mailing Address - Street 1:1720 NICHOLASVILLE RD
Mailing Address - Street 2:SUITE 400
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40503-1475
Mailing Address - Country:US
Mailing Address - Phone:859-278-0363
Mailing Address - Fax:859-277-6938
Practice Address - Street 1:1720 NICHOLASVILLE RD
Practice Address - Street 2:SUITE 400
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40503-1475
Practice Address - Country:US
Practice Address - Phone:859-278-0363
Practice Address - Fax:859-277-6938
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-10-27
Last Update Date:2007-07-08
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Provider Licenses
StateLicense IDTaxonomies
KY15567207VG0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VG0400XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64155674Medicaid
KY64155674Medicaid
KY0325003Medicare ID - Type Unspecified