Provider Demographics
NPI:1538200050
Name:LAIRD MCMULLEN, MOLLY F (MD)
Entity type:Individual
Prefix:
First Name:MOLLY
Middle Name:F
Last Name:LAIRD MCMULLEN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:MOLLY
Other - Middle Name:F
Other - Last Name:MCMULLEN-LAIRD
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:820 GRANGER AVE
Mailing Address - Street 2:
Mailing Address - City:ANN ARBOR
Mailing Address - State:MI
Mailing Address - Zip Code:48104-3828
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1825 W STADIUM BLVD
Practice Address - Street 2:
Practice Address - City:ANN ARBOR
Practice Address - State:MI
Practice Address - Zip Code:48103-4501
Practice Address - Country:US
Practice Address - Phone:734-222-1491
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-08
Last Update Date:2011-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301069605207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4301069605OtherMEDICAL LICENSE
MI4301069605OtherMEDICAL LICENSE
MIOM48250Medicare ID - Type Unspecified