Provider Demographics
NPI:1699793075
Name:MOORE, PHILIP C (MD)
Entity type:Individual
Prefix:
First Name:PHILIP
Middle Name:C
Last Name:MOORE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 198
Mailing Address - Street 2:
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67201-0198
Mailing Address - Country:US
Mailing Address - Phone:316-685-6091
Mailing Address - Fax:
Practice Address - Street 1:805 PAMPLICO HWY
Practice Address - Street 2:
Practice Address - City:FLORENCE
Practice Address - State:SC
Practice Address - Zip Code:29505-6019
Practice Address - Country:US
Practice Address - Phone:843-664-3301
Practice Address - Fax:843-664-3723
Is Sole Proprietor?:No
Enumeration Date:2006-07-17
Last Update Date:2023-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC27707207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC277079Medicaid
SCF358277234Medicare PIN
F35827Medicare UPIN
SCP00208044Medicare PIN