Provider Demographics
NPI:1265542245
Name:MOORE, FREADDIE V (CRNA)
Entity type:Individual
Prefix:MS
First Name:FREADDIE
Middle Name:V
Last Name:MOORE
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:MRS
Other - First Name:FREADDIE
Other - Middle Name:V
Other - Last Name:HART
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:CRNA
Mailing Address - Street 1:804 SCOTT NIXON MEMORIAL DRIVE
Mailing Address - Street 2:
Mailing Address - City:AUGUSTA
Mailing Address - State:GA
Mailing Address - Zip Code:30907-2464
Mailing Address - Country:US
Mailing Address - Phone:800-394-4445
Mailing Address - Fax:706-650-1034
Practice Address - Street 1:30200 TELEGRAPH ROAD
Practice Address - Street 2:220
Practice Address - City:BINGHAM FARMS
Practice Address - State:MI
Practice Address - Zip Code:48025-4502
Practice Address - Country:US
Practice Address - Phone:248-258-5058
Practice Address - Fax:248-927-5058
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2012-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704100987367H00000X, 367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No367H00000XPhysician Assistants & Advanced Practice Nursing ProvidersAnesthesiologist Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4834216-10Medicaid
11802435OtherCAQH
MI4834216-10Medicaid