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General NPI Number Information
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NPI Number | 1356451942
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Entity Type | Individual
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Provider Name | KEITH J. MOODY D.O
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Gender | Male
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Dates
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Enumeration Date | 08/30/2006
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Last Update Date | 11/19/2014
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Provider Practice Location Address
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Address Line | 1501 W CHISHOLM ST
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City | ALPENA
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State | MI
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Zip | 49707-1401
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Country | US
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Telephone | 989-340-1211
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Fax | 989-340-1214
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Provider Business Mailing Address
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Address Line | 10850 E TRAVERSE HWY STE 4400
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City | TRAVERSE CITY
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State | MI
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Zip | 49684-1364
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Country | US
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Telephone | 231-346-6800
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Fax | 989-340-1214
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207R00000X
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Taxonomy Name | Internal Medicine Physician
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License Number | 5101008328
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License Number State | MI
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