Basic Information
| Provider Information | |||||||||
| NPI: | 1477618551 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MOORE | ||||||||
| FirstName: | HEIDI | ||||||||
| MiddleName: | JILL | ||||||||
| NamePrefix: | MRS. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 600 BLAIR PARK RD | ||||||||
| Address2: | SUITE 190 | ||||||||
| City: | WILLISTON | ||||||||
| State: | VT | ||||||||
| PostalCode: | 054957586 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8028724343 | ||||||||
| FaxNumber: | 8028720282 | ||||||||
| Practice Location | |||||||||
| Address1: | 159 MARGARET ST | ||||||||
| Address2: | SUITE 103 | ||||||||
| City: | PLATTSBURGH | ||||||||
| State: | NY | ||||||||
| PostalCode: | 129011874 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5185620151 | ||||||||
| FaxNumber: | 5185622718 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/27/2006 | ||||||||
| LastUpdateDate: | 02/05/2014 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | 223912-1 | NY | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 02743295 | 05 | NY | MEDICAID |