Healthcare Provider Details

I. General information

NPI: 1497709513
Provider Name (Legal Business Name): SCOTT MACLEOD MOORE M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/22/2006
Last Update Date: 08/07/2025
Certification Date: 08/07/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13699 OLD US 12
CHELSEA MI
48118
US

IV. Provider business mailing address

13699 OLD US 12
CHELSEA MI
48118
US

V. Phone/Fax

Practice location:
  • Phone: 734-475-4500
  • Fax: 734-475-4507
Mailing address:
  • Phone: 734-475-4500
  • Fax: 734-475-4507

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number4301073339
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: