Healthcare Provider Details

I. General information

NPI: 1477952026
Provider Name (Legal Business Name): JACOB MOISE M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/20/2014
Last Update Date: 08/20/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

329 BEL AIR DR.
GLENVIEW IL
60025
US

IV. Provider business mailing address

329 BEL AIR DR.
GLENVIEW IL
60025
US

V. Phone/Fax

Practice location:
  • Phone: 847-998-9070
  • Fax:
Mailing address:
  • Phone: 847-998-9070
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207VE0102X
TaxonomyReproductive Endocrinology Physician
License Number036062927
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: