Healthcare Provider Details

I. General information

NPI: 1063421899
Provider Name (Legal Business Name): ILLINOIS UROGYNECOLOGY, LTD.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/08/2006
Last Update Date: 08/09/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1875 DEMPSTER ST SUITE 665
PARK RIDGE IL
60068-1186
US

IV. Provider business mailing address

1875 DEMPSTER ST SUITE 665
PARK RIDGE IL
60068-1186
US

V. Phone/Fax

Practice location:
  • Phone: 847-825-1590
  • Fax: 847-825-1604
Mailing address:
  • Phone: 847-825-1590
  • Fax: 847-825-1604

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207VG0400X
TaxonomyGynecology Physician
License Number
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code207VF0040X
TaxonomyUrogynecology and Reconstructive Pelvic Surgery (Obstetrics & Gynecology) Physician
License Number
License Number StateIL

VIII. Authorized Official

Name: MICHAEL MOEN
Title or Position: PRES
Credential: MD
Phone: 847-825-1590