Healthcare Provider Details

I. General information

NPI: 1124181755
Provider Name (Legal Business Name): KENNETH J. MOQUIN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/18/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

HENRY FORD HEALTH SYSTEM 2799 WEST GRAND BOULEVARD
DETROIT MI
48202
US

IV. Provider business mailing address

HENRY FORD HEALTH SYSTEM 2799 WEST GRAND BOULEVARD
DETROIT MI
48202
US

V. Phone/Fax

Practice location:
  • Phone: 313-916-2436
  • Fax:
Mailing address:
  • Phone: 313-916-2436
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208200000X
TaxonomyPlastic Surgery Physician
License Number4301063210
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: