Basic Information
| Provider Information | |||||||||
| NPI: | 1043495039 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MOLITERNO | ||||||||
| FirstName: | DALE | ||||||||
| MiddleName: | LEE | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | DO | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 501 LAPEER | ||||||||
| Address2: | |||||||||
| City: | SAGINAW | ||||||||
| State: | MI | ||||||||
| PostalCode: | 486071208 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9897596464 | ||||||||
| FaxNumber: | 9893998233 | ||||||||
| Practice Location | |||||||||
| Address1: | 501 LAPEER | ||||||||
| Address2: | |||||||||
| City: | SAGINAW | ||||||||
| State: | MI | ||||||||
| PostalCode: | 486071208 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9897596300 | ||||||||
| FaxNumber: | 9897596454 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/08/2008 | ||||||||
| LastUpdateDate: | 02/25/2011 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208D00000X | 5101007489 | MI | Y | Allopathic & Osteopathic Physicians | General Practice |
ID Information
| ID | Type | State | Issuer | Description | 58146 | 01 | MN | HEALTHPLAN OF MICHIGAN | OTHER | 180962 | 01 | MI | GREAT LAKES HEALTH PLAN/UNITED HEALTHCARE | OTHER | 381908328-464 | 01 | MN | CARE SOURCE OF MICHIGAN | OTHER | 0157313895 | 01 | MI | HEALTH PLUS OF MICHIGAN | OTHER | 1058377 | 01 | MI | MCLAREN HEALTH PLAN OF MICHIGAN | OTHER | 070G310660 | 01 | MI | BLUE CROSS BLUE SHIELD | OTHER | 1043495039 | 05 | MI | MEDICAID | 080G310660 | 01 | MI | BLUE CARE NETWORK OF MICHIGAN | OTHER | 381908328 | 01 | MN | HCAP | OTHER | 1043495039 | 01 | MI | MOLINA HEALTHCARE OF MICHIGAN | OTHER | 381908328 | 01 | MI | PRIORITY HEALTH | OTHER |