Basic Information
Provider Information | |||||||||
NPI: | 1346265196 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | MOORE | ||||||||
FirstName: | DANIEL | ||||||||
MiddleName: | S. | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | HENRY FORD HEALTH SYSTEM | ||||||||
Address2: | 2799 WEST GRAND BOULEVARD | ||||||||
City: | DETROIT | ||||||||
State: | MI | ||||||||
PostalCode: | 48202 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3139169106 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | HENRY FORD HEALTH SYSTEM | ||||||||
Address2: | 2799 WEST GRAND BOULEVARD | ||||||||
City: | DETROIT | ||||||||
State: | MI | ||||||||
PostalCode: | 48202 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3139169106 | ||||||||
FaxNumber: | 3139161249 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/13/2006 | ||||||||
LastUpdateDate: | 04/05/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 04/05/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 4301087116 | MI | Y |   | Allopathic & Osteopathic Physicians | Internal Medicine |   |
ID Information
ID | Type | State | Issuer | Description | 490836510 | 05 | MI |   | MEDICAID | 700H262220 | 01 |   | BLUE CROSS-BLUE CROSS | OTHER | DM087116 | 01 |   | CHAMPUS-CHAMPUS | OTHER | DM087116 | 01 |   | COMMERCIAL-COMMERCIAL NUMBER | OTHER |