Healthcare Provider Details

I. General information

NPI: 1275050361
Provider Name (Legal Business Name): NATHANIEL RAY MOXON
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/29/2017
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

240 E HURON ST STE 1-200
CHICAGO IL
60611-2909
US

IV. Provider business mailing address

NORTHWESTERN MEDICINE MCGAW MEDICAL CENTER 240 E HURON STREET, SUITE 1-200
CHICAGO IL
60611
US

V. Phone/Fax

Practice location:
  • Phone: 312-503-7975
  • Fax:
Mailing address:
  • Phone: 312-503-7975
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: