Healthcare Provider Details

I. General information

NPI: 1780295683
Provider Name (Legal Business Name): MOONLIGHT PEDIATRICS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/13/2020
Last Update Date: 08/18/2020
Certification Date: 08/18/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 BRONZE POINTE BLVD STE 1A
SWANSEA IL
62226-1045
US

IV. Provider business mailing address

866 REVERE DR
SAINT LOUIS MO
63141-8818
US

V. Phone/Fax

Practice location:
  • Phone: 216-778-0808
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QU0200X
TaxonomyUrgent Care Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. QAMAR ZAMAN
Title or Position: DIRECTOR
Credential: MD
Phone: 216-778-0808