Basic Information
| Provider Information | |||||||||
| NPI: | 1609819416 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MOORE | ||||||||
| FirstName: | ALFRED | ||||||||
| MiddleName: | DENTON | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 287 | ||||||||
| Address2: | |||||||||
| City: | GREENVILLE | ||||||||
| State: | SC | ||||||||
| PostalCode: | 296020287 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8647298330 | ||||||||
| FaxNumber: | 8647510479 | ||||||||
| Practice Location | |||||||||
| Address1: | 975 W FARIS RD | ||||||||
| Address2: | |||||||||
| City: | GREENVILLE | ||||||||
| State: | SC | ||||||||
| PostalCode: | 296054241 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8647298330 | ||||||||
| FaxNumber: | 8647510479 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/13/2006 | ||||||||
| LastUpdateDate: | 10/26/2016 | ||||||||
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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 | 207P00000X | 010654 | SC | N | Allopathic & Osteopathic Physicians | Emergency Medicine | 207R00000X | 010654 | SC | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 106548 | 05 | SC | MEDICAID | P00211213 | 01 | SC | RAILROAD-MEDICARE | OTHER |