Provider Demographics
NPI:1588733349
Name:KENNETH P MOORE, MD
Entity type:Organization
Organization Name:KENNETH P MOORE, MD
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO RUBY VALLEY UROLOGY
Authorized Official - Prefix:DR
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:PAGE
Authorized Official - Last Name:MOORE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:775-738-2218
Mailing Address - Street 1:1995 ERRECART BLVD
Mailing Address - Street 2:SUITE 207
Mailing Address - City:ELKO
Mailing Address - State:NV
Mailing Address - Zip Code:89801-8337
Mailing Address - Country:US
Mailing Address - Phone:775-738-2218
Mailing Address - Fax:775-738-2219
Practice Address - Street 1:1995 ERRECART BLVD
Practice Address - Street 2:SUITE 207
Practice Address - City:ELKO
Practice Address - State:NV
Practice Address - Zip Code:89801-8337
Practice Address - Country:US
Practice Address - Phone:775-738-2218
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-07
Last Update Date:2008-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208800000XAllopathic & Osteopathic PhysiciansUrologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV100506958Medicaid
G44010Medicare UPIN
101490Medicare ID - Type Unspecified