Provider Demographics
NPI:1053395798
Name:MOULTON GROUP PC
Entity type:Organization
Organization Name:MOULTON GROUP PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:PAULETTE
Authorized Official - Middle Name:PATRICIA
Authorized Official - Last Name:MOULTON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:734-241-4950
Mailing Address - Street 1:PO BOX 2503
Mailing Address - Street 2:
Mailing Address - City:MONROE
Mailing Address - State:MI
Mailing Address - Zip Code:48161-7503
Mailing Address - Country:US
Mailing Address - Phone:734-241-4950
Mailing Address - Fax:734-243-4269
Practice Address - Street 1:2246 N MONROE ST
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:MI
Practice Address - Zip Code:48162-4254
Practice Address - Country:US
Practice Address - Phone:734-241-4950
Practice Address - Fax:734-243-4269
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-12-06
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301042774174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4893843Medicaid
MI0705810691OtherBCBS
MIOP16880Medicare ID - Type Unspecified
MI0705810691OtherBCBS