Healthcare Provider Details

I. General information

NPI: 1548342355
Provider Name (Legal Business Name): GEORGE THOMAS MOYNIHAN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/20/2006
Last Update Date: 04/29/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 E ERIE ST SUITE 640
CHICAGO IL
60611-2740
US

IV. Provider business mailing address

1 E ERIE ST SUITE 640
CHICAGO IL
60611-2740
US

V. Phone/Fax

Practice location:
  • Phone: 312-988-9300
  • Fax: 312-988-9310
Mailing address:
  • Phone: 312-988-9300
  • Fax: 312-988-9310

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207YS0123X
TaxonomyFacial Plastic Surgery Physician
License Number036-104040
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: