MEDICARE: DR. GEORGE THOMAS MOYNIHAN M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207YS0123X	Facial Plastic Surgery Physician	036-104040	IL

General Provider Information

NPI Number	:	1548342355
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. GEORGE THOMAS MOYNIHAN M.D.

Provider Business Mailing Address
First Line	:	1 E ERIE ST
Second Line	:	SUITE 640
City	:	CHICAGO
State	:	IL
Zip	:	60611-2740
Country	:	US
Telephone Number	:	312-988-9300
Fax Number	:	312-988-9310

Provider Business Practice Location Address
First Line	:	1 E ERIE ST
Second Line	:	SUITE 640
City	:	CHICAGO
State	:	IL
Zip	:	60611-2740
Country	:	US
Telephone Number	:	312-988-9300
Fax Number	:	312-988-9310

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/20/2006
Last Update Date	:	04/29/2014

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