Basic Information
| Provider Information | |||||||||
| NPI: | 1609173798 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | M. JANE MOORE, MD. LLC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3260 PROVIDENCE DR. STE 526 | ||||||||
| Address2: | |||||||||
| City: | ANCHORAGE | ||||||||
| State: | AK | ||||||||
| PostalCode: | 995084608 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9075693600 | ||||||||
| FaxNumber: | 9075693200 | ||||||||
| Practice Location | |||||||||
| Address1: | 3260 PROVIDENCE DR STE 526 | ||||||||
| Address2: | |||||||||
| City: | ANCHORAGE | ||||||||
| State: | AK | ||||||||
| PostalCode: | 995084608 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9075693600 | ||||||||
| FaxNumber: | 9075693200 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/25/2011 | ||||||||
| LastUpdateDate: | 02/25/2011 | ||||||||
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| AuthorizedOfficialLastName: | CARROLL | ||||||||
| AuthorizedOfficialFirstName: | JILL | ||||||||
| AuthorizedOfficialMiddleName: | M | ||||||||
| AuthorizedOfficialTitleorPosition: | OFFICE MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 9075693600 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QP2300X | 952570 | AK | Y | Ambulatory Health Care Facilities | Clinic/Center | Primary Care |
ID Information
| ID | Type | State | Issuer | Description | MD8920 | 05 | AK | MEDICAID |