Provider Demographics
NPI:1487638573
Name:MORETSKY, ROBERT I (DO)
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:I
Last Name:MORETSKY
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25600 SCHOENHERR RD
Mailing Address - Street 2:
Mailing Address - City:WARREN
Mailing Address - State:MI
Mailing Address - Zip Code:48089-1447
Mailing Address - Country:US
Mailing Address - Phone:586-777-6170
Mailing Address - Fax:586-777-6582
Practice Address - Street 1:25600 SCHOENHERR RD
Practice Address - Street 2:
Practice Address - City:WARREN
Practice Address - State:MI
Practice Address - Zip Code:48089-1447
Practice Address - Country:US
Practice Address - Phone:586-777-6170
Practice Address - Fax:586-777-6582
Is Sole Proprietor?:No
Enumeration Date:2005-12-01
Last Update Date:2011-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101005323207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIE26627OtherHAP
MIP00237883OtherRR MEDICARE
MI700H217350OtherBLUE SHIELD
MI1487638573Medicaid
MI0M18760-001Medicare ID - Type Unspecified
MI1487638573Medicaid
MI0M92440021Medicare PIN