Basic Information
| Provider Information | |||||||||
| NPI: | 1396762910 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MOORE | ||||||||
| FirstName: | TIMOTHY | ||||||||
| MiddleName: | D | ||||||||
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| Credential: | D.O. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2630 HIGHWAY K | ||||||||
| Address2: | |||||||||
| City: | O FALLON | ||||||||
| State: | MO | ||||||||
| PostalCode: | 633686624 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6362405454 | ||||||||
| FaxNumber: | 6369805335 | ||||||||
| Practice Location | |||||||||
| Address1: | 2630 HIGHWAY K | ||||||||
| Address2: | |||||||||
| City: | O FALLON | ||||||||
| State: | MO | ||||||||
| PostalCode: | 633686624 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6362405454 | ||||||||
| FaxNumber: | 6369805335 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/17/2006 | ||||||||
| LastUpdateDate: | 02/15/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 02/15/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | 106405 | MO | N | Allopathic & Osteopathic Physicians | Emergency Medicine | 207Q00000X | 106405 | MO | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 245208616 | 05 | MO | MEDICAID | 1396762910 | 05 | MO | MEDICAID |