Healthcare Provider Details

I. General information

NPI: 1205863792
Provider Name (Legal Business Name): JACOB L MOSKOVIC M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/28/2006
Last Update Date: 01/29/2024
Certification Date: 05/30/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

121 S WILKE RD STE 226
ARLINGTON HEIGHTS IL
60005-1530
US

IV. Provider business mailing address

121 S WILKE RD STE 226
ARLINGTON HEIGHTS IL
60005-1530
US

V. Phone/Fax

Practice location:
  • Phone: 847-590-0050
  • Fax: 847-590-0080
Mailing address:
  • Phone: 847-590-0050
  • Fax: 847-590-0080

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084P0802X
TaxonomyAddiction Psychiatry Physician
License Number036-040989
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code2084P0805X
TaxonomyGeriatric Psychiatry Physician
License Number036-040989
License Number StateIL
# 3
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number036-040989
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: