=====================================================
General NPI Number Information
=====================================================
NPI Number | 1285668772
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MICHAEL J MOORE MD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/10/2006
-----------------------------------------------------
Last Update Date | 12/04/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 133 E BRUSH HILL RD STE 310
-----------------------------------------------------
City | ELMHURST
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60126-5662
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 331-221-9003
-----------------------------------------------------
Fax | 331-221-2743
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4201 WINFIELD RD FL 4
-----------------------------------------------------
City | WARRENVILLE
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60555-4025
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 331-221-6377
-----------------------------------------------------
Fax | 331-221-2357
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207RC0200X
-----------------------------------------------------
Taxonomy Name | Critical Care Medicine (Internal Medicine) Physician
-----------------------------------------------------
License Number | 036101366
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207RP1001X
-----------------------------------------------------
Taxonomy Name | Pulmonary Disease Physician
-----------------------------------------------------
License Number | 036101366
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------