Healthcare Provider Details

I. General information

NPI: 1518514066
Provider Name (Legal Business Name): VICTORIA MOORE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/20/2019
Last Update Date: 10/18/2021
Certification Date: 10/18/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

550 W OGDEN AVE
HINSDALE IL
60521-3186
US

IV. Provider business mailing address

900 RAND RD STE 300
DES PLAINES IL
60016-2359
US

V. Phone/Fax

Practice location:
  • Phone: 630-323-6116
  • Fax: 630-323-6169
Mailing address:
  • Phone: 847-324-3976
  • Fax: 847-929-1154

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number085-007296
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: