Basic Information
| Provider Information | |||||||||
| NPI: | 1073590485 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MOORE | ||||||||
| FirstName: | ELIZABETH | ||||||||
| MiddleName: | ANN | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 190 HANDLEY RD | ||||||||
| Address2: | STE A | ||||||||
| City: | TYRONE | ||||||||
| State: | GA | ||||||||
| PostalCode: | 302902178 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7709975714 | ||||||||
| FaxNumber: | 7709972844 | ||||||||
| Practice Location | |||||||||
| Address1: | 190 HANDLEY RD | ||||||||
| Address2: | |||||||||
| City: | TYRONE | ||||||||
| State: | GA | ||||||||
| PostalCode: | 302902178 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7709975714 | ||||||||
| FaxNumber: | 7709972810 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/28/2005 | ||||||||
| LastUpdateDate: | 12/09/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 12/09/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207V00000X | GA43434 | GA | Y | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |
ID Information
| ID | Type | State | Issuer | Description | 000753827D | 05 | GA | MEDICAID |