Basic Information
| Provider Information | |||||||||
| NPI: | 1942614953 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MOON | ||||||||
| FirstName: | SHAUN | ||||||||
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| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1 GENESYS PKWY | ||||||||
| Address2: | |||||||||
| City: | GRAND BLANC | ||||||||
| State: | MI | ||||||||
| PostalCode: | 484398065 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 5014 MCLAIN ST | ||||||||
| Address2: | |||||||||
| City: | SWARTZ CREEK | ||||||||
| State: | MI | ||||||||
| PostalCode: | 484731215 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8106065000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/17/2014 | ||||||||
| LastUpdateDate: | 01/01/2016 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 5101021324 | MI | Y | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.