Healthcare Provider Details

I. General information

NPI: 1679584767
Provider Name (Legal Business Name): LISA A. MOORE M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/11/2006
Last Update Date: 02/02/2023
Certification Date: 02/02/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2900 N LAKE SHORE DR
CHICAGO IL
60657-5640
US

IV. Provider business mailing address

185 PENNY AVE
EAST DUNDEE IL
60118-1454
US

V. Phone/Fax

Practice location:
  • Phone: 773-665-3000
  • Fax:
Mailing address:
  • Phone: 847-836-7015
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208VP0014X
TaxonomyInterventional Pain Medicine Physician
License Number036095350
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number036095350
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: