Basic Information
Provider Information | |||||||||
NPI: | 1871599282 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | MOORE | ||||||||
FirstName: | TERESA | ||||||||
MiddleName: | A.F. | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 927 | ||||||||
Address2: | 5 E ALVON ROAD, SUITE 7 | ||||||||
City: | WHITE SULPHUR SPRINGS | ||||||||
State: | WV | ||||||||
PostalCode: | 249862373 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3045365030 | ||||||||
FaxNumber: | 3045365051 | ||||||||
Practice Location | |||||||||
Address1: | 312 KING STREET | ||||||||
Address2: |   | ||||||||
City: | KEYSVILLE | ||||||||
State: | VA | ||||||||
PostalCode: | 239474540 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4347368801 | ||||||||
FaxNumber: | 4347360292 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/22/2005 | ||||||||
LastUpdateDate: | 10/15/2011 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 0101052933 | VA | Y |   | Allopathic & Osteopathic Physicians | Family Medicine |   |
ID Information
ID | Type | State | Issuer | Description | 10026074 | 01 | VA | OPTIMA/SENTARA | OTHER | 61459601 | 01 | VA | BLACK LUNG/FECA | OTHER | 6774742 | 01 | VA | CIGNA | OTHER | 345650 | 01 | VA | ANTHEM | OTHER | 5116589 | 01 | VA | AETNA | OTHER | 5625351 | 05 | VA |   | MEDICAID | 1871599282 | 05 | VA |   | MEDICAID | 2605469 | 01 | VA | AETNA | OTHER | 453599 | 01 | VA | ANTHEM | OTHER |