Basic Information
| Provider Information | |||||||||
| NPI: | 1497074041 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MOORE | ||||||||
| FirstName: | EDGAR | ||||||||
| MiddleName: | CHARLES | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | JR. | ||||||||
| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2000 PERIMETER PARK DR STE 200 | ||||||||
| Address2: | |||||||||
| City: | MORRISVILLE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 275608442 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 701 DOCTORS DR | ||||||||
| Address2: | SUITE A | ||||||||
| City: | KINSTON | ||||||||
| State: | NC | ||||||||
| PostalCode: | 285011589 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2527755999 | ||||||||
| FaxNumber: | 2522081647 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/21/2010 | ||||||||
| LastUpdateDate: | 05/11/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 05/11/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2086S0102X | OS014259 | PA | N | Allopathic & Osteopathic Physicians | Surgery | Surgical Critical Care | 2086S0127X | OS014259 | PA | N | Allopathic & Osteopathic Physicians | Surgery | Trauma Surgery | 208600000X | 2013-00327 | NC | Y | Allopathic & Osteopathic Physicians | Surgery |
ID Information
| ID | Type | State | Issuer | Description | 179J0 | 01 | NC | BCBS NC | OTHER | 1497074041 | 05 | NC | MEDICAID |