1528351491 NPI number — DR. LIANNE ELIZABETH MOORE D.O.

Table of content: DR. LIANNE ELIZABETH MOORE D.O. (NPI 1528351491)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1528351491 NPI number — DR. LIANNE ELIZABETH MOORE D.O.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MOORE
Provider First Name:
LIANNE
Provider Middle Name:
ELIZABETH
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
D.O.
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:
1528351491
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/24/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
14 NORTH MAIN STREET, SUITE 101
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CLARKSTON
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48346-2830
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
724-544-1044
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1 GENESYS PKWY
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GRAND BLANC
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48439-8065
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
810-606-5980
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
05/25/2011

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: 207P00000X , with the licence number:  5101019340 , 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)





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