Basic Information
| Provider Information | |||||||||
| NPI: | 1356451942 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MOODY | ||||||||
| FirstName: | KEITH | ||||||||
| MiddleName: | J. | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | D.O | ||||||||
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| Mailing Information | |||||||||
| Address1: | 10850 E TRAVERSE HWY | ||||||||
| Address2: | STE 4400 | ||||||||
| City: | TRAVERSE CITY | ||||||||
| State: | MI | ||||||||
| PostalCode: | 496841364 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2313466800 | ||||||||
| FaxNumber: | 9893401214 | ||||||||
| Practice Location | |||||||||
| Address1: | 1501 W CHISHOLM ST | ||||||||
| Address2: | |||||||||
| City: | ALPENA | ||||||||
| State: | MI | ||||||||
| PostalCode: | 497071401 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9893401211 | ||||||||
| FaxNumber: | 9893401214 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/30/2006 | ||||||||
| LastUpdateDate: | 11/19/2014 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 5101008328 | MI | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 1150900464 | 01 | MI | HEALTH PLUS OF MI | OTHER | 1006214 | 01 | MI | MCLAREN HEALTH PLAN | OTHER | 1150900464 | 01 | MI | FEP | OTHER | 1006214 | 01 | MI | MCLAREN HEALTH ADVANTAGE | OTHER | 4164290 | 05 | MI | MEDICAID | 110197522 | 01 | MI | UNITED HEALTHCARE | OTHER | 16613 | 01 | MI | COMMUNITY CHOICE | OTHER | 28233 | 01 | MI | PRIORITY HEALTH | OTHER | 4220040 | 01 | MI | AETNA | OTHER | 50900464 | 01 | MI | BLUE CARE NETWORK | OTHER | 1150900464 | 01 | MI | BCBSM | OTHER |