Healthcare Provider Details

I. General information

NPI: 1043369747
Provider Name (Legal Business Name): PATRICIA L. MOODY MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/10/2007
Last Update Date: 07/09/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2780 MCFARLAND RD
ROCKFORD IL
61107-6807
US

IV. Provider business mailing address

2780 MCFARLAND RD
ROCKFORD IL
61107-6807
US

V. Phone/Fax

Practice location:
  • Phone: 815-971-2000
  • Fax: 815-637-0400
Mailing address:
  • Phone: 815-971-2000
  • Fax: 815-637-0400

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number036103063
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: