Healthcare Provider Details

I. General information

NPI: 1942867270
Provider Name (Legal Business Name): CLAIRE ECCLES MOORE MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: CLAIRE ELISABETH ECCLES

II. Dates (important events)

Enumeration Date: 05/22/2019
Last Update Date: 05/06/2022
Certification Date: 05/06/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

225 E CHICAGO AVE
CHICAGO IL
60611-2991
US

IV. Provider business mailing address

225 E CHICAGO AVE
CHICAGO IL
60611-2991
US

V. Phone/Fax

Practice location:
  • Phone: 401-444-8805
  • Fax: 401-444-2988
Mailing address:
  • Phone: 312-227-6616
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number036160152
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: