Basic Information
| Provider Information | |||||||||
| NPI: | 1629001714 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MOYER | ||||||||
| FirstName: | DONNA | ||||||||
| MiddleName: | R | ||||||||
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| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 32627 | ||||||||
| Address2: | |||||||||
| City: | DETROIT | ||||||||
| State: | MI | ||||||||
| PostalCode: | 482320627 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8667441452 | ||||||||
| FaxNumber: | 5864124101 | ||||||||
| Practice Location | |||||||||
| Address1: | 1375 N MAIN ST | ||||||||
| Address2: | |||||||||
| City: | LAPEER | ||||||||
| State: | MI | ||||||||
| PostalCode: | 484461350 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8106675500 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/09/2006 | ||||||||
| LastUpdateDate: | 02/08/2013 | ||||||||
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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 | 2085R0202X | 5101010638 | MI | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | CA3518 | 01 | MI | MEDICARE RR GROUP PIN | OTHER | 300111755 | 01 | MI | RRMC | OTHER | 310D460020 | 01 | MI | BCBS GROUP PIN | OTHER | 4095728 | 05 | MI | MEDICAID |