Basic Information
| Provider Information | |||||||||
| NPI: | 1790727741 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MOORE | ||||||||
| FirstName: | ANGELA | ||||||||
| MiddleName: | R | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4071 TATES CREEK CENTRE DR | ||||||||
| Address2: | SUITE 202 | ||||||||
| City: | LEXINGTON | ||||||||
| State: | KY | ||||||||
| PostalCode: | 405173062 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8592604385 | ||||||||
| FaxNumber: | 8592604386 | ||||||||
| Practice Location | |||||||||
| Address1: | 1760 NICHOLASVILLE RD | ||||||||
| Address2: | SUITE 401 | ||||||||
| City: | LEXINGTON | ||||||||
| State: | KY | ||||||||
| PostalCode: | 405031471 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8592606537 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/12/2006 | ||||||||
| LastUpdateDate: | 12/04/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 12/04/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | 31216 | KY | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 64312168 | 05 | KY | MEDICAID |