MEDICARE: MOULTON GROUP PC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	174400000X	Specialist	4301042774	MI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	0705810691	OTHER	MI	BCBS

General Provider Information

NPI Number	:	1053395798
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MOULTON GROUP PC

Provider Business Mailing Address
First Line	:	PO BOX 2503
Second Line	:
City	:	MONROE
State	:	MI
Zip	:	48161-7503
Country	:	US
Telephone Number	:	734-241-4950
Fax Number	:	734-243-4269

Provider Business Practice Location Address
First Line	:	2246 N MONROE ST
Second Line	:
City	:	MONROE
State	:	MI
Zip	:	48162-4254
Country	:	US
Telephone Number	:	734-241-4950
Fax Number	:	734-243-4269

Authorized Official
Title or Position	:	OWNER
Name	:	DR. PAULETTE PATRICIA MOULTON
Credential	:	M.D.
Telephone Number	:	734-241-4950

Provider Enumeration Date	:	12/06/2005
Last Update Date	:	08/22/2020

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Directions to “MOULTON GROUP PC ” Practice Location

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