Basic Information
| Provider Information | |||||||||
| NPI: | 1083839120 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MOORE | ||||||||
| FirstName: | LOLONYA | ||||||||
| MiddleName: | R | ||||||||
| NamePrefix: | |||||||||
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| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | PAIGE | ||||||||
| OtherFirstName: | LOLONYA | ||||||||
| OtherMiddleName: | R | ||||||||
| OtherNamePrefix: | |||||||||
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| OtherCredential: | MD | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 30701 WOODWARD AVENUE | ||||||||
| Address2: | SUITE S200 | ||||||||
| City: | ROYAL OAK | ||||||||
| State: | MI | ||||||||
| PostalCode: | 48073 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2485847600 | ||||||||
| FaxNumber: | 2485847606 | ||||||||
| Practice Location | |||||||||
| Address1: | 30701 WOODWARD AVE | ||||||||
| Address2: | SUITE S200 | ||||||||
| City: | ROYAL OAK | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480730987 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2485847600 | ||||||||
| FaxNumber: | 2485847606 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/16/2007 | ||||||||
| LastUpdateDate: | 11/20/2008 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | 4301084006 | MI | Y | Other Service Providers | Specialist | 207V00000X | 430184006 | MI | N | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |
No ID Information.