Provider Demographics
NPI:1043369747
Name:MOODY, PATRICIA L (MD)
Entity Type:Individual
Prefix:
First Name:PATRICIA
Middle Name:L
Last Name:MOODY
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 1:2780 MCFARLAND RD
Mailing Address - Street 2:
Mailing Address - City:ROCKFORD
Mailing Address - State:IL
Mailing Address - Zip Code:61107-6807
Mailing Address - Country:US
Mailing Address - Phone:815-971-2000
Mailing Address - Fax:815-637-0400
Practice Address - Street 1:2780 MCFARLAND RD
Practice Address - Street 2:
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61107-6807
Practice Address - Country:US
Practice Address - Phone:815-971-2000
Practice Address - Fax:815-637-0400
Is Sole Proprietor?:No
Enumeration Date:2007-01-10
Last Update Date:2015-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036103063208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036103063Medicaid
ILH53280Medicare UPIN
IL200314Medicare PIN