Healthcare Provider Details

I. General information

NPI: 1750762928
Provider Name (Legal Business Name): JACOB ROBERT MOORE M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/14/2015
Last Update Date: 06/14/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5841 S MARYLAND AVE RM L539
CHICAGO IL
60637-1447
US

IV. Provider business mailing address

100 E 14TH ST APT 803
CHICAGO IL
60605-3666
US

V. Phone/Fax

Practice location:
  • Phone: 773-702-9500
  • Fax:
Mailing address:
  • Phone: 815-988-3623
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number125066516
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: