1457465171 NPI number — DR. GLYNDA MELONSON MOORER M.D.

Table of content: DR. GLYNDA MELONSON MOORER M.D. (NPI 1457465171)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1457465171 NPI number — DR. GLYNDA MELONSON MOORER M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MOORER
Provider First Name:
GLYNDA
Provider Middle Name:
MELONSON
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1457465171
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/11/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
OLIN HEALTH CENTER
Provider Second Line Business Mailing Address:
EAST CIRCLE DRIVE
Provider Business Mailing Address City Name:
EAST LANSING
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48824-1037
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
517-884-6546
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
EAST CIRCLE DRIVE
Provider Second Line Business Practice Location Address:
OLIN HEALTH CENTER
Provider Business Practice Location Address City Name:
EAST LANSING
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48824
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
517-355-4510
Provider Business Practice Location Address Fax Number:
517-432-9528
Provider Enumeration Date:
08/19/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  4301039370 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 1375049 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".




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