Basic Information
| Provider Information | |||||||||
| NPI: | 1891736815 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MOORE | ||||||||
| FirstName: | THOMAS | ||||||||
| MiddleName: | B. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3020 SAINT JOHNS BLVD | ||||||||
| Address2: | STE A | ||||||||
| City: | JOPLIN | ||||||||
| State: | MO | ||||||||
| PostalCode: | 648041564 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4177815387 | ||||||||
| FaxNumber: | 4177817174 | ||||||||
| Practice Location | |||||||||
| Address1: | 3020 SAINT JOHNS BLVD | ||||||||
| Address2: | STE A | ||||||||
| City: | JOPLIN | ||||||||
| State: | MO | ||||||||
| PostalCode: | 648041564 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4177815387 | ||||||||
| FaxNumber: | 4177817174 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/09/2006 | ||||||||
| LastUpdateDate: | 02/10/2012 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RC0000X | R3B12 | MO | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease |
ID Information
| ID | Type | State | Issuer | Description | 100164600E | 05 | KS | MEDICAID | P00800249 | 01 | KS | RAIL ROAD MEDICARE | OTHER | 100164600F | 05 | KS | MEDICAID | 1891736815 | 01 | KS | BLUE CROSS OF KANSAS | OTHER | P00800228 | 01 | MO | RAIL ROAD MEDICARE | OTHER | 201669439 | 05 | MO | MEDICAID | 21620038 | 01 | MO | BLUE CROSS OF KANSAS CITY | OTHER |