Provider Demographics
NPI:1033282579
Name:PETER C. MOODY, M.D., P.L.C.
Entity Type:Organization
Organization Name:PETER C. MOODY, M.D., P.L.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:MR
Authorized Official - First Name:PETER
Authorized Official - Middle Name:CAMPBELL
Authorized Official - Last Name:MOODY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:810-733-3780
Mailing Address - Street 1:1286 S LINDEN RD
Mailing Address - Street 2:SUITE A
Mailing Address - City:FLINT
Mailing Address - State:MI
Mailing Address - Zip Code:48532-3407
Mailing Address - Country:US
Mailing Address - Phone:810-733-3780
Mailing Address - Fax:810-230-1672
Practice Address - Street 1:1286 S LINDEN RD
Practice Address - Street 2:SUITE A
Practice Address - City:FLINT
Practice Address - State:MI
Practice Address - Zip Code:48532-3407
Practice Address - Country:US
Practice Address - Phone:810-733-3780
Practice Address - Fax:810-230-1672
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-15
Last Update Date:2011-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary DiseaseGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4697529Medicaid
MI02510801OtherBCBS
MI0N88340Medicare ID - Type Unspecified
MI02510801OtherBCBS