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General NPI Number Information
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NPI Number | 1780295683
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Entity Type | Organization
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Legal Business Name | MOONLIGHT PEDIATRICS LLC
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Dates
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Enumeration Date | 08/13/2020
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Last Update Date | 08/18/2020
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Provider Practice Location Address
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Address Line | 1 BRONZE POINTE BLVD STE 1A
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City | SWANSEA
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State | IL
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Zip | 62226-1045
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Country | US
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Telephone | 216-778-0808
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Fax |
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Provider Business Mailing Address
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Address Line | 866 REVERE DR
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City | SAINT LOUIS
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State | MO
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Zip | 63141-8818
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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 | DIRECTOR
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Name | DR. QAMAR ZAMAN
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Credential | MD
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Telephone | 216-778-0808
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QU0200X
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Taxonomy Name | Urgent Care Clinic/Center
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 208000000X
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Taxonomy Name | Pediatrics Physician
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License Number |
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License Number State |
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