Provider Demographics
NPI:1275502445
Name:MOORE, MARY D (MD)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:D
Last Name:MOORE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1000 HOUGHTON AVE
Mailing Address - Street 2:
Mailing Address - City:SAGINAW
Mailing Address - State:MI
Mailing Address - Zip Code:48602-5303
Mailing Address - Country:US
Mailing Address - Phone:989-746-7500
Mailing Address - Fax:989-746-7752
Practice Address - Street 1:1000 HOUGHTON AVE
Practice Address - Street 2:
Practice Address - City:SAGINAW
Practice Address - State:MI
Practice Address - Zip Code:48602-5303
Practice Address - Country:US
Practice Address - Phone:989-746-7500
Practice Address - Fax:989-746-7752
Is Sole Proprietor?:No
Enumeration Date:2006-03-17
Last Update Date:2021-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI43010808452080P0216X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0216XAllopathic & Osteopathic PhysiciansPediatricsPediatric Rheumatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
3503906282OtherBCBS
MI4440356Medicaid
E67807Medicare UPIN
3503906282OtherBCBS