Provider Demographics
NPI:1053437079
Name:MOORE, ETHEL LAMAR (MD)
Entity type:Individual
Prefix:
First Name:ETHEL
Middle Name:LAMAR
Last Name:MOORE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:RR 1 BOX 77
Mailing Address - Street 2:
Mailing Address - City:HARLEM
Mailing Address - State:MT
Mailing Address - Zip Code:59526-9706
Mailing Address - Country:US
Mailing Address - Phone:406-353-3137
Mailing Address - Fax:406-353-3229
Practice Address - Street 1:RR 1 BOX 67
Practice Address - Street 2:
Practice Address - City:HARLEM
Practice Address - State:MT
Practice Address - Zip Code:59526-9705
Practice Address - Country:US
Practice Address - Phone:406-353-3100
Practice Address - Fax:406-353-3229
Is Sole Proprietor?:No
Enumeration Date:2007-03-21
Last Update Date:2008-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARC 6449207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ARC-6449OtherLICENSE
MT8HZ67BMedicare PIN
MTB18597Medicare UPIN
MT8HZ78BMedicare PIN