Provider Demographics
NPI:1992710743
Name:TOWLES-MOORE, STACY (MD)
Entity type:Individual
Prefix:
First Name:STACY
Middle Name:
Last Name:TOWLES-MOORE
Suffix:
Gender:F
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 97
Mailing Address - Street 2:
Mailing Address - City:GADSDEN
Mailing Address - State:AL
Mailing Address - Zip Code:35902-0097
Mailing Address - Country:US
Mailing Address - Phone:256-492-0131
Mailing Address - Fax:
Practice Address - Street 1:1316 NOBLE ST
Practice Address - Street 2:
Practice Address - City:ANNISTON
Practice Address - State:AL
Practice Address - Zip Code:36201-4643
Practice Address - Country:US
Practice Address - Phone:256-492-0131
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-30
Last Update Date:2013-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL14423207R00000X
MS18858207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL511-14627(ANNISTON)OtherBLUE CROSS
AL125268Medicaid
MS8589530Medicaid
AL511-14627(ANNISTON)OtherBLUE CROSS
MS110001953Medicare ID - Type Unspecified