Healthcare Provider Details

I. General information

NPI: 1104877414
Provider Name (Legal Business Name): PHILIP A MOORE M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/12/2006
Last Update Date: 04/16/2024
Certification Date: 04/16/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2020 OGDEN AVE STE 400
AURORA IL
60504-5898
US

IV. Provider business mailing address

2000 OGDEN AVE
AURORA IL
60504-5893
US

V. Phone/Fax

Practice location:
  • Phone: 630-692-5563
  • Fax: 630-692-5564
Mailing address:
  • Phone: 630-499-2404
  • Fax: 630-499-4750

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number036088408
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: