Individual
MR. JEFFERY W MOORE
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
CRNA
Contact information
Practice address
1000 S MAIN ST, TIPTON, IN 46072-9753
(765) 675-8521
(765) 675-8520
Mailing address
1000 S MAIN ST, TIPTON, IN 46072-9753
(765) 675-8521
(765) 675-8520
Taxonomy
Speciality
Code
Description
License number
State
367500000X
Certified Registered Nurse Anesthetist
Primary
28087122A
IN
367H00000X
Anesthesiologist Assistant
28087122
IN
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
000000603596
ANTHEM - TIPTON HOSPITAL
IN
05
—
200345230
—
IN
05
—
200345230A
—
IN
Enumeration date
12/06/2005
Last updated
10/01/2014
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