Provider Demographics
NPI:1497895106
Name:MORANG CHESTER CLINIC P C
Entity Type:Organization
Organization Name:MORANG CHESTER CLINIC P C
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:BARRY
Authorized Official - Middle Name:
Authorized Official - Last Name:BRAVER
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:313-884-0900
Mailing Address - Street 1:17520 CHESTER ST
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48224-1212
Mailing Address - Country:US
Mailing Address - Phone:313-884-0900
Mailing Address - Fax:313-884-8062
Practice Address - Street 1:17520 CHESTER ST
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48224-1212
Practice Address - Country:US
Practice Address - Phone:313-884-0900
Practice Address - Fax:313-884-8062
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-08
Last Update Date:2007-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101007774207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0188200304OtherBCBSM PIN
MI2808979Medicaid
MI8820030Medicare ID - Type Unspecified
MI2808979Medicaid