Healthcare Provider Details

I. General information

NPI: 1851483572
Provider Name (Legal Business Name): RENATA CHARISSA MOORE M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/29/2006
Last Update Date: 02/12/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1990 E LAKE SHORE DR
DECATUR IL
62521-3811
US

IV. Provider business mailing address

210 W MCKINLEY AVE SUITE 1
DECATUR IL
62526-5858
US

V. Phone/Fax

Practice location:
  • Phone: 217-464-2900
  • Fax: 217-464-2909
Mailing address:
  • Phone: 217-876-6600
  • Fax: 217-876-6606

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0001X
TaxonomyRadiation Oncology Physician
License Number036093129
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: