Healthcare Provider Details

I. General information

NPI: 1316435548
Provider Name (Legal Business Name): ADAM JOSEPH MOON
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/24/2018
Last Update Date: 09/14/2022
Certification Date: 09/14/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1000 HEALTH CENTER DR
MATTOON IL
61938-4644
US

IV. Provider business mailing address

10468 E KINGWOOD DR
EFFINGHAM IL
62401-4354
US

V. Phone/Fax

Practice location:
  • Phone: 217-258-2440
  • Fax: 217-258-2186
Mailing address:
  • Phone: 217-343-1411
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QS1000X
TaxonomyStudent Health Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number1316435548
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: