Provider Demographics
NPI:1750363867
Name:MOORE, ROBERT WILLARD (MD)
Entity type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:WILLARD
Last Name:MOORE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1498 FREEDOM BLVD
Mailing Address - Street 2:
Mailing Address - City:FLORENCE
Mailing Address - State:SC
Mailing Address - Zip Code:29505-6077
Mailing Address - Country:US
Mailing Address - Phone:843-676-2720
Mailing Address - Fax:843-676-2722
Practice Address - Street 1:1498 FREEDOM BLVD
Practice Address - Street 2:
Practice Address - City:FLORENCE
Practice Address - State:SC
Practice Address - Zip Code:29505-6077
Practice Address - Country:US
Practice Address - Phone:843-676-2720
Practice Address - Fax:843-676-2722
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-15
Last Update Date:2016-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC14794207X00000X, 207XS0106X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XS0106XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryHand Surgery
No207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC147941Medicaid
SCP00110451OtherMEDICARE ID
SCP00110451OtherMEDICARE ID
SCQ267837938Medicare PIN