Basic Information
| Provider Information | |||||||||
| NPI: | 1700973435 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MOORE | ||||||||
| FirstName: | DUANE | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3691 RUTGER ST | ||||||||
| Address2: | PROVIDER ENROLLMENT | ||||||||
| City: | SAINT LOUIS | ||||||||
| State: | MO | ||||||||
| PostalCode: | 631102515 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3149776828 | ||||||||
| FaxNumber: | 3149776777 | ||||||||
| Practice Location | |||||||||
| Address1: | 3635 VISTA AVE | ||||||||
| Address2: | WEST PAVILION, ROOM 315 | ||||||||
| City: | SAINT LOUIS | ||||||||
| State: | MO | ||||||||
| PostalCode: | 631102539 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3145778776 | ||||||||
| FaxNumber: | 3142685697 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/06/2006 | ||||||||
| LastUpdateDate: | 10/16/2014 | ||||||||
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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 | 2005011345 | MO | Y | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | P00273332 | 01 | MO | RR MEDICARE | OTHER | 207197302 | 05 | MO | MEDICAID |