Provider Demographics
NPI:1396780292
Name:SIEBERT MOAZZAM P C
Entity type:Organization
Organization Name:SIEBERT MOAZZAM P C
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:A
Authorized Official - Last Name:SIEBERT
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:309-353-1833
Mailing Address - Street 1:2205 STATE ST
Mailing Address - Street 2:
Mailing Address - City:PEKIN
Mailing Address - State:IL
Mailing Address - Zip Code:61554-3936
Mailing Address - Country:US
Mailing Address - Phone:309-353-1833
Mailing Address - Fax:
Practice Address - Street 1:401 MAIN STREET
Practice Address - Street 2:SUITE 1200
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61602-1242
Practice Address - Country:US
Practice Address - Phone:309-671-8749
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-17
Last Update Date:2011-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036101798208G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)Group - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL206647Medicare ID - Type UnspecifiedMEDICARE
ILIL1881Medicare PIN
IL368480Medicare ID - Type UnspecifiedMEDICARE