Healthcare Provider Details

I. General information

NPI: 1104407980
Provider Name (Legal Business Name): REECE MOORE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/14/2021
Last Update Date: 03/08/2025
Certification Date: 02/14/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

275 MICHIGAN ST NE FL 9
GRAND RAPIDS MI
49503-2531
US

IV. Provider business mailing address

275 MICHIGAN ST NE FL 9
GRAND RAPIDS MI
49503-2531
US

V. Phone/Fax

Practice location:
  • Phone: 866-989-7999
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208200000X
TaxonomyPlastic Surgery Physician
License Number4351049935
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: