Provider Demographics
NPI:1295917524
Name:KEITH J MOODY D O P C
Entity type:Organization
Organization Name:KEITH J MOODY D O P C
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KEITH
Authorized Official - Middle Name:J
Authorized Official - Last Name:MOODY D O
Authorized Official - Suffix:
Authorized Official - Credentials:D O
Authorized Official - Phone:989-893-9705
Mailing Address - Street 1:200 S WENONA ST
Mailing Address - Street 2:SUITE 225
Mailing Address - City:BAY CITY
Mailing Address - State:MI
Mailing Address - Zip Code:48706-8820
Mailing Address - Country:US
Mailing Address - Phone:989-893-9705
Mailing Address - Fax:989-893-8206
Practice Address - Street 1:200 S WENONA ST
Practice Address - Street 2:SUITE 225
Practice Address - City:BAY CITY
Practice Address - State:MI
Practice Address - Zip Code:48706-8820
Practice Address - Country:US
Practice Address - Phone:989-893-9705
Practice Address - Fax:989-893-8206
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-28
Last Update Date:2007-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101008328207R00000X, 207RG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric MedicineGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4164290Medicaid
1150900464OtherBLUE CROSS BLUE SHIELD MI
1006214OtherMCLAREN HEALTH PLAN
1150900464OtherFEP BLUE CROSS
50900464OtherBLUE CARE NETWORK
28233OtherPRIORITY HEALTH
16613OtherCOMMUNITY CHOICE
4220040OtherAETNA
1150900464OtherHEALTH PLUS OF MI
50900464OtherBLUE CARE NETWORK