Healthcare Provider Details

I. General information

NPI: 1225039837
Provider Name (Legal Business Name): MICHAEL ALLEN MOORE PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/04/2005
Last Update Date: 05/09/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4200 DIVISION AVE N
COMSTOCK PARK MI
49321-9546
US

IV. Provider business mailing address

1925 BRETON RD SE SUITE 201
GRAND RAPIDS MI
49506-4810
US

V. Phone/Fax

Practice location:
  • Phone: 616-252-1600
  • Fax: 616-252-1666
Mailing address:
  • Phone: 616-252-1600
  • Fax: 616-252-1666

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number5601002580
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: