Healthcare Provider Details

I. General information

NPI: 1124095278
Provider Name (Legal Business Name): TODD A MOYER-BRAILEAN DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/07/2006
Last Update Date: 06/27/2023
Certification Date: 06/27/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4660 S HAGADORN RD STE 210
EAST LANSING MI
48823-5353
US

IV. Provider business mailing address

804 SERVICE RD STE A109B
EAST LANSING MI
48824-7015
US

V. Phone/Fax

Practice location:
  • Phone: 517-355-4205
  • Fax: 517-364-8119
Mailing address:
  • Phone: 517-355-4205
  • Fax: 517-355-4202

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207VF0040X
TaxonomyUrogynecology and Reconstructive Pelvic Surgery (Obstetrics & Gynecology) Physician
License Number5101009519
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: