Basic Information
| Provider Information | |||||||||
| NPI: | 1861607194 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MOORE | ||||||||
| FirstName: | VICKIE | ||||||||
| MiddleName: | S | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 815 EAST PARKWAY | ||||||||
| Address2: | SUITE #7 | ||||||||
| City: | GATLINBURG | ||||||||
| State: | TN | ||||||||
| PostalCode: | 377384915 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8654362811 | ||||||||
| FaxNumber: | 8654362812 | ||||||||
| Practice Location | |||||||||
| Address1: | 815 EAST PARKWAY | ||||||||
| Address2: | SUITE #7 | ||||||||
| City: | GATLINBURG | ||||||||
| State: | TN | ||||||||
| PostalCode: | 377384915 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8654362811 | ||||||||
| FaxNumber: | 8654362812 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/11/2007 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | MD0000014031 | TN | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 4378288 | 01 | TN | AETNA | OTHER | 0072043 | 01 | TN | BCBS | OTHER | 7068691 | 01 | TN | CIGNA | OTHER |