Healthcare Provider Details

I. General information

NPI: 1275502445
Provider Name (Legal Business Name): MARY D MOORE M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/17/2006
Last Update Date: 03/30/2021
Certification Date: 03/30/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1000 HOUGHTON AVE
SAGINAW MI
48602-5303
US

IV. Provider business mailing address

1000 HOUGHTON AVE
SAGINAW MI
48602-5303
US

V. Phone/Fax

Practice location:
  • Phone: 989-746-7500
  • Fax: 989-746-7752
Mailing address:
  • Phone: 989-746-7500
  • Fax: 989-746-7752

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080P0216X
TaxonomyPediatric Rheumatology Physician
License Number4301080845
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: