Provider Demographics
NPI:1104877414
Name:MOORE, PHILIP A (MD)
Entity type:Individual
Prefix:DR
First Name:PHILIP
Middle Name:A
Last Name:MOORE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Mailing Address - Street 1:2000 OGDEN AVE
Mailing Address - Street 2:
Mailing Address - City:AURORA
Mailing Address - State:IL
Mailing Address - Zip Code:60504-5893
Mailing Address - Country:US
Mailing Address - Phone:630-499-2404
Mailing Address - Fax:630-499-4750
Practice Address - Street 1:2020 OGDEN AVE STE 400
Practice Address - Street 2:
Practice Address - City:AURORA
Practice Address - State:IL
Practice Address - Zip Code:60504-5898
Practice Address - Country:US
Practice Address - Phone:630-692-5563
Practice Address - Fax:630-692-5564
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-12
Last Update Date:2024-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036088408207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL216616Medicare PIN