Basic Information
| Provider Information | |||||||||
| NPI: | 1457464554 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MOORE | ||||||||
| FirstName: | GEORGE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 225 S MAIN ST | ||||||||
| Address2: | |||||||||
| City: | MC COLL | ||||||||
| State: | SC | ||||||||
| PostalCode: | 295702020 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 225 S MAIN ST | ||||||||
| Address2: | |||||||||
| City: | MC COLL | ||||||||
| State: | SC | ||||||||
| PostalCode: | 295702020 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8435235751 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/16/2006 | ||||||||
| LastUpdateDate: | 09/05/2017 | ||||||||
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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 | 207Q00000X | 5711 | SC | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 057119 | 05 | SC | MEDICAID | P00169807 | 01 | SC | RAILROAD MEDICARE PTAN | OTHER |