Provider Demographics
NPI:1215120811
Name:MCQUILLAN, MOIRA E (MD)
Entity type:Individual
Prefix:
First Name:MOIRA
Middle Name:E
Last Name:MCQUILLAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12050 S HARLEM AVE
Mailing Address - Street 2:STE A
Mailing Address - City:PALOS HEIGHTS
Mailing Address - State:IL
Mailing Address - Zip Code:60463-2803
Mailing Address - Country:US
Mailing Address - Phone:708-671-1500
Mailing Address - Fax:708-671-1535
Practice Address - Street 1:12050 S HARLEM AVE
Practice Address - Street 2:STE A
Practice Address - City:PALOS HEIGHTS
Practice Address - State:IL
Practice Address - Zip Code:60463-2803
Practice Address - Country:US
Practice Address - Phone:708-671-1500
Practice Address - Fax:708-671-1535
Is Sole Proprietor?:No
Enumeration Date:2007-08-27
Last Update Date:2022-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036119095207Q00000X
IL036-119095207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036119095OtherSTATE LICENSE
IL036119095OtherSTATE LICENSE