Basic Information
| Provider Information | |||||||||
| NPI: | 1720049109 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MOORE | ||||||||
| FirstName: | JASON | ||||||||
| MiddleName: | L | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 27400 FRANKLIN RD | ||||||||
| Address2: | #B707 | ||||||||
| City: | SOUTHFIELD | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480342358 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 45 10TH ST W | ||||||||
| Address2: | |||||||||
| City: | SAINT PAUL | ||||||||
| State: | MN | ||||||||
| PostalCode: | 551021062 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6512323000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/28/2006 | ||||||||
| LastUpdateDate: | 11/16/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 11/16/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | 61613 | MN | N | Allopathic & Osteopathic Physicians | Emergency Medicine | 207P00000X | 4301080458 | MI | N | Allopathic & Osteopathic Physicians | Emergency Medicine | 207PE0004X | 4301080458 | MI | N | Allopathic & Osteopathic Physicians | Emergency Medicine | Emergency Medical Services | 207P00000X | 39945 | IA | Y | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 104715823 | 05 | MI | MEDICAID | 104785416 | 05 | MI | MEDICAID | 104785425 | 05 | MI | MEDICAID | JM080458 | 01 | MI | BC/BS OF MI | OTHER |