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General NPI Number Information
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NPI Number | 1144097254
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Entity Type | Organization
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Legal Business Name | JACOB R MOORE MD SC
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Dates
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Enumeration Date | 12/08/2023
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Last Update Date | 12/08/2023
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Provider Practice Location Address
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Address Line | 303 N JACKSON ST
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City | MORRISON
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State | IL
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Zip | 61270-3042
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Country | US
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Telephone | 815-772-4003
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Fax |
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Provider Business Mailing Address
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Address Line | 3037 N SEMINARY AVE
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City | CHICAGO
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State | IL
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Zip | 60657-4335
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | PRESIDENT/TRESURER/SECRETARY
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Name | JACOB MOORE
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Credential | MD
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Telephone | 815-988-3623
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QE0002X
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Taxonomy Name | Emergency Care Clinic/Center
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License Number |
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License Number State |
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