Basic Information
| Provider Information | |||||||||
| NPI: | 1376639518 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MOORE | ||||||||
| FirstName: | LORAN | ||||||||
| MiddleName: | PETE | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3430 NEWBURG RD | ||||||||
| Address2: | SUITE 150 | ||||||||
| City: | LOUISVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 402182497 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5022383178 | ||||||||
| FaxNumber: | 5022383653 | ||||||||
| Practice Location | |||||||||
| Address1: | 4606 GREENWOOD RD | ||||||||
| Address2: | |||||||||
| City: | LOUISVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 402583726 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5029372209 | ||||||||
| FaxNumber: | 5029338714 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/05/2006 | ||||||||
| LastUpdateDate: | 09/11/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 24953 | KY | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207RS0012X | 24953 | KY | N | Allopathic & Osteopathic Physicians | Internal Medicine | Sleep Medicine | 207RP1001X | 24953 | KY | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Pulmonary Disease |
ID Information
| ID | Type | State | Issuer | Description | 200003670 | 01 | IN | INDIANA MEDICAID | OTHER |