MEDICARE: LEYLA MOOSSAVI M.D.

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	207V00000X	Obstetrics & Gynecology Physician	4301065333	MI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1603700871	OTHER	MI	BCBSM
2	200000005818	OTHER	MI	PHP COMMERCIAL
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
4	1006844	OTHER	MI	MCLAREN HEALTH PLAN
5	0986427	OTHER	MI	HEALTHPLUS COMMERCIAL
6	1006843	OTHER	MI	MCLAREN HEALTH PLAN
7	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1457387151
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LEYLA MOOSSAVI M.D.

Provider Business Mailing Address
First Line	:	1621 E BROOMFIELD ST
Second Line	:	SUITE A
City	:	MT PLEASANT
State	:	MI
Zip	:	48858-5427
Country	:	US
Telephone Number	:	989-775-7492
Fax Number	:	989-775-6892

Provider Business Practice Location Address
First Line	:	1621 E BROOMFIELD ST
Second Line	:	SUITE A
City	:	MOUNT PLEASANT
State	:	MI
Zip	:	48858-5427
Country	:	US
Telephone Number	:	989-775-7492
Fax Number	:	989-775-6892

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/24/2006
Last Update Date	:	09/06/2012

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Directions to “ LEYLA MOOSSAVI M.D.” Practice Location

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