Provider Demographics
NPI:1194081349
Name:PEGGY RICHARDSON-MOORE MD PC
Entity type:Organization
Organization Name:PEGGY RICHARDSON-MOORE MD PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MD
Authorized Official - Prefix:DR
Authorized Official - First Name:PEGGY
Authorized Official - Middle Name:
Authorized Official - Last Name:RICHARDSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:313-564-8930
Mailing Address - Street 1:211 GLENDALE ST STE 200
Mailing Address - Street 2:
Mailing Address - City:HIGHLAND PARK
Mailing Address - State:MI
Mailing Address - Zip Code:48203-3231
Mailing Address - Country:US
Mailing Address - Phone:313-564-8930
Mailing Address - Fax:313-564-8933
Practice Address - Street 1:211 GLENDALE ST STE 200
Practice Address - Street 2:
Practice Address - City:HIGHLAND PARK
Practice Address - State:MI
Practice Address - Zip Code:48203-3231
Practice Address - Country:US
Practice Address - Phone:313-564-8930
Practice Address - Fax:313-564-8933
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-04-02
Last Update Date:2012-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301041722207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI5102934Medicaid
MIF16750Medicare UPIN