Provider Demographics
NPI:1720433238
Name:MOORE, MICHAEL
Entity type:Individual
Prefix:
First Name:MICHAEL
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 1:645 E MISSOURI AVE
Mailing Address - Street 2:STE 300
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85012-1351
Mailing Address - Country:US
Mailing Address - Phone:602-262-8900
Mailing Address - Fax:602-262-8890
Practice Address - Street 1:645 E MISSOURI AVE STE 300
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85012-1351
Practice Address - Country:US
Practice Address - Phone:602-262-8900
Practice Address - Fax:602-262-8890
Is Sole Proprietor?:Yes
Enumeration Date:2016-05-03
Last Update Date:2021-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ60351207L00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ087531Medicaid