Healthcare Provider Details

I. General information

NPI: 1932527017
Provider Name (Legal Business Name): ADILLS MOOSA DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/04/2014
Last Update Date: 01/06/2022
Certification Date: 01/06/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1750 E LAKE SHORE DR
DECATUR IL
62521-3803
US

IV. Provider business mailing address

4111 FRANKLIN ST
MICHIGAN CITY IN
46360-7803
US

V. Phone/Fax

Practice location:
  • Phone: 217-464-1440
  • Fax:
Mailing address:
  • Phone: 219-879-5400
  • Fax: 219-879-5900

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2083X0100X
TaxonomyOccupational Medicine Physician
License NumberR-10649
License Number StateIA
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code2083X0100X
TaxonomyOccupational Medicine Physician
License Number02005491A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: