=====================================================
General NPI Number Information
=====================================================
NPI Number | 1477562882
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | EARL G MOEHN M D P C
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/05/2006
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 100 BELLEVIEW ST
-----------------------------------------------------
City | MOUNT CLEMENS
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48043-2241
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 586-463-4204
-----------------------------------------------------
Fax | 586-268-0953
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 100 BELLEVIEW ST
-----------------------------------------------------
City | MOUNT CLEMENS
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48043-2241
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 586-463-4204
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PHYSICIAN
-----------------------------------------------------
Name | DR. EARL G MOEHN
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 586-463-4204
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208600000X
-----------------------------------------------------
Taxonomy Name | Surgery Physician
-----------------------------------------------------
License Number | 4301025603
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------