NPIMap

Individual provider Active NPI

Charles Robert Moore, MD

  • Urology Physician
  • Hattiesburg, MS
National Provider Identifier
1801058821
Registry record updated Oct 24, 2011
On this page

Key facts

NPPES NPI Registry
Primary specialty
Urology PhysicianTaxonomy code 208800000X
License
20677 Issued in MS
Practice address
139 Fairfield Dr
Hattiesburg, MS 39402-1303
Phone
(601) 450-2417
Fax
(601) 450-2434
NPI assigned
Jun 30, 2008
Last updated
Oct 24, 2011By the provider in NPPES
Sex
Male
Sole proprietor
No

NPPES NPI Registry

Updated by the provider on Oct 24, 2011

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 2

Specialty (taxonomy)CodeLicenseStatePrimary
Student in an Organized Health Care Education/Training Program 390200000X TRN#12298 FL
Urology Physician 208800000X 20677 MS Primary

Addresses

Primary practice location

139 Fairfield Dr
Hattiesburg, MS 39402-1303

Mailing address

139 Fairfield Dr
Hattiesburg, MS 39402-1303
Phone (601) 450-2417

Other identifiers 1

IdentifierTypeStateIssuer
05137554MedicaidMS

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in MS
Eligible to order & refer
  • Part B services
  • Medical equipment
  • Home health
  • Power mobility devices
  • Hospice
Green means eligible to order or refer.

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
I20090727000543 MS Practitioner - Urology 2769535574 Reassigns benefits to 2 organizations

Care Compare profile

Medicare Care Compare
Specialty
Urology
Education
Louisiana State University School of Medicine in New Orleans, 2003
Medicare assignment
Accepts the Medicare-approved amount as payment in full
Group practices
Southern Urology, P. a.Group PAC ID 0042287575, 4 clinicians

Practice addresses (Care Compare)

139 Fairfield Dr
Hattiesburg, MS 39402-1303
Phone (601) 450-2401

Hospital & facility affiliations

Merit-based Incentive Payment System (MIPS)

Final score
75 of 100Reported as group

Merit-based Incentive Payment System (MIPS)

Final score
88.07 of 100Reported as apm
Quality
73.89
Promoting interoperability
100
Improvement activities
40

Procedures performed for Medicare patients

ProcedureNumber of procedures
Prostate resection1-10
Removal of tissue1-10

National Provider Directory

National Provider Directory
Medicare enrollment (NPD)
Enrolled
Credentials
Doctor of Medicine

State licenses

LicenseStateTypeSpecialty
TRN#12298FLMDStudent in an Organized Health Care Education/Training Program

Practice roles

OrganizationSpecialtyStatusNew patients
Southern Urology, P. a. CurrentSince Aug 1, 2009 Accepting new patients
Wesley Physician Services LLC CurrentSince Apr 1, 2014 Accepting new patients

Locations

139 Fairfield Dr
Hattiesburg, MS 39402
Phone (601) 450-2401

39 Franklin Rd
Ste 220
Hattiesburg, MS 39402
Phone (601) 296-3050

5001 Hardy St
Hattiesburg, MS 39402
Phone (601) 268-8000

Interoperability endpoints

  • FHIR API: https://api.platform.athenahealth.com/1930/brand/2/csg/102/fhir/r4
  • Direct secure messaging: southernsurgicalassociatespa.charlesmoore@150945.advancedmd-direct.com

Organizations & group practices 2

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships, National Provider Directory roles and organizations whose NPPES authorized official is this provider.

Hospital & facility affiliations 5

Hospitals and other facilities this clinician is affiliated with according to Medicare Care Compare.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1214784000000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1319414400000",
    "number": "1801058821",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "139 FAIRFIELD DR",
            "city": "HATTIESBURG",
            "state": "MS",
            "postal_code": "394021303",
            "telephone_number": "601-450-2417",
            "fax_number": "601-450-2434"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "139 FAIRFIELD DR",
            "city": "HATTIESBURG",
            "state": "MS",
            "postal_code": "394021303",
            "telephone_number": "601-450-2417",
            "fax_number": "601-450-2434"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "MOORE",
        "first_name": "CHARLES",
        "middle_name": "ROBERT",
        "credential": "MD",
        "sole_proprietor": "NO",
        "sex": "M",
        "enumeration_date": "2008-06-30",
        "last_updated": "2011-10-24",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "390200000X",
            "taxonomy_group": "",
            "desc": "Student in an Organized Health Care Education/Training Program",
            "state": "FL",
            "license": "TRN#12298",
            "primary": false
        },
        {
            "code": "208800000X",
            "taxonomy_group": "",
            "desc": "Urology",
            "state": "MS",
            "license": "20677",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "05137554",
            "state": "MS"
        }
    ],
    "endpoints": [],
    "other_names": []
}

Other providers in Hattiesburg, MS

Sources for this page

Verify at the official NPI Registry.