Provider Demographics
NPI:1477562882
Name:EARL G MOEHN M D P C
Entity Type:Organization
Organization Name:EARL G MOEHN M D P C
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:EARL
Authorized Official - Middle Name:G
Authorized Official - Last Name:MOEHN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:586-463-4204
Mailing Address - Street 1:100 BELLEVIEW ST
Mailing Address - Street 2:
Mailing Address - City:MOUNT CLEMENS
Mailing Address - State:MI
Mailing Address - Zip Code:48043-2241
Mailing Address - Country:US
Mailing Address - Phone:586-463-4204
Mailing Address - Fax:
Practice Address - Street 1:100 BELLEVIEW ST
Practice Address - Street 2:
Practice Address - City:MOUNT CLEMENS
Practice Address - State:MI
Practice Address - Zip Code:48043-2241
Practice Address - Country:US
Practice Address - Phone:586-463-4204
Practice Address - Fax:586-268-0953
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-05
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301025603208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4301025603OtherLICENSE
P00070675OtherRAIL ROAD MEDICARE
MI1720810Medicaid
4301025603OtherBLUE CROSS BLUE SHIELD MI
4301025603OtherBLUE CROSS BLUE SHIELD MI
P00070675OtherRAIL ROAD MEDICARE