Basic Information
| Provider Information | |||||||||
| NPI: | 1740209253 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MOORE, JR | ||||||||
| FirstName: | CHARLES | ||||||||
| MiddleName: | F | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 100 E LIBERTY ST | ||||||||
| Address2: | SUITE 800 | ||||||||
| City: | LOUISVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 402021434 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5023673360 | ||||||||
| FaxNumber: | 5023673365 | ||||||||
| Practice Location | |||||||||
| Address1: | 727 HOSPITAL DR | ||||||||
| Address2: | |||||||||
| City: | SHELBYVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 400651660 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5023673360 | ||||||||
| FaxNumber: | 5023673365 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/18/2006 | ||||||||
| LastUpdateDate: | 10/26/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/26/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 41169 | KY | Y | Allopathic & Osteopathic Physicians | Internal Medicine | 207RR0500X | 41169 | KY | N | Allopathic & Osteopathic Physicians | Internal Medicine | Rheumatology | 208M00000X | 01056663A | IN | N | Allopathic & Osteopathic Physicians | Hospitalist |
ID Information
| ID | Type | State | Issuer | Description | 000000386253 | 01 | IN | BCBS - GATEWAY | OTHER | 64102056 | 05 | KY | MEDICAID | 000000374581 | 01 | IN | BCBS - MARY STREET | OTHER | P00248435 | 01 | IN | RR MCARE PIN | OTHER | 200518340 | 05 | IN | MEDICAID |