Provider Demographics
NPI:1588783633
Name:MOORE, CHRISTOPHER
Entity type:Individual
Prefix:
First Name:CHRISTOPHER
Middle Name:
Last Name:MOORE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1100 REID PKWY
Mailing Address - Street 2:MEDICAL STAFF SERVICES
Mailing Address - City:RICHMOND
Mailing Address - State:IN
Mailing Address - Zip Code:47374-1157
Mailing Address - Country:US
Mailing Address - Phone:765-962-6053
Mailing Address - Fax:765-935-7401
Practice Address - Street 1:1050 REID PKWY
Practice Address - Street 2:SUITE 120
Practice Address - City:RICHMOND
Practice Address - State:IN
Practice Address - Zip Code:47374-1155
Practice Address - Country:US
Practice Address - Phone:765-962-6053
Practice Address - Fax:765-935-7401
Is Sole Proprietor?:No
Enumeration Date:2007-03-28
Last Update Date:2021-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01069535A208600000X, 208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN201041530Medicaid
000000724246OtherANTHEM - RPA
OH0067107Medicaid
OH0067107Medicaid