Provider Demographics
NPI:1699722793
Name:MOISAN, TERRENCE C (MD)
Entity type:Individual
Prefix:DR
First Name:TERRENCE
Middle Name:C
Last Name:MOISAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10660 W 143RD ST STE B
Mailing Address - Street 2:
Mailing Address - City:ORLAND PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60462-1989
Mailing Address - Country:US
Mailing Address - Phone:708-349-0055
Mailing Address - Fax:708-460-8031
Practice Address - Street 1:12255 S 80TH AVE
Practice Address - Street 2:
Practice Address - City:PALOS HEIGHTS
Practice Address - State:IL
Practice Address - Zip Code:60463-1270
Practice Address - Country:US
Practice Address - Phone:708-448-1400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-27
Last Update Date:2008-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036050798207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036050798OtherMEDICAID
IL290007170OtherPALMETTO RR MEDICARE
IL290007170OtherPALMETTO RR MEDICARE