Provider Demographics
NPI:1487725487
Name:MOORE, PATRICK DALE (DC)
Entity type:Individual
Prefix:
First Name:PATRICK
Middle Name:DALE
Last Name:MOORE
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:502 E MARKET ST
Mailing Address - Street 2:
Mailing Address - City:CRAWFORDSVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:47933-1817
Mailing Address - Country:US
Mailing Address - Phone:765-362-1500
Mailing Address - Fax:765-361-8919
Practice Address - Street 1:8258 ROCKVILLE ROAD
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46214-0000
Practice Address - Country:US
Practice Address - Phone:317-429-5400
Practice Address - Fax:317-429-5401
Is Sole Proprietor?:No
Enumeration Date:2006-11-13
Last Update Date:2011-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN08001595111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000344411OtherANTHEM
IN5288041OtherAETNA
IN200043740AMedicaid
IN201466872OtherTAX ID
IN201466872100OtherCARESOURCE
IN000000344411OtherANTHEM
IN220010Medicare UPIN