Provider Demographics
NPI:1699300582
Name:EDILBERTO MORENO MD PC
Entity type:Organization
Organization Name:EDILBERTO MORENO MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:TAMMY
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:WEBER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:810-344-9073
Mailing Address - Street 1:8384 HOLLY RD STE 2
Mailing Address - Street 2:
Mailing Address - City:GRAND BLANC
Mailing Address - State:MI
Mailing Address - Zip Code:48439-1975
Mailing Address - Country:US
Mailing Address - Phone:810-344-9073
Mailing Address - Fax:810-771-4541
Practice Address - Street 1:8384 HOLLY RD STE 2
Practice Address - Street 2:
Practice Address - City:GRAND BLANC
Practice Address - State:MI
Practice Address - Zip Code:48439-1975
Practice Address - Country:US
Practice Address - Phone:810-344-9073
Practice Address - Fax:810-771-4541
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-03-11
Last Update Date:2020-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Single Specialty