Healthcare Provider Details

I. General information

NPI: 1740293562
Provider Name (Legal Business Name): JOHN A MOORE M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/14/2006
Last Update Date: 05/07/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

611 W PARK ST
URBANA IL
61801-2529
US

IV. Provider business mailing address

611 W PARK ST BWPC
URBANA IL
61801-2529
US

V. Phone/Fax

Practice location:
  • Phone: 217-383-3100
  • Fax: 217-383-4468
Mailing address:
  • Phone: 217-383-6792
  • Fax: 217-383-4752

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080P0201X
TaxonomyPediatric Allergy/Immunology Physician
License Number036042907
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: