Provider Demographics
NPI:1245208453
Name:MOON'S MULTI SPECIALTY CLINIC, SC
Entity Type:Organization
Organization Name:MOON'S MULTI SPECIALTY CLINIC, SC
Other - Org Name:MOON'S FOOT AND ANKLE CLINIC, SC
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JUNG
Authorized Official - Middle Name:
Authorized Official - Last Name:MOON
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:847-573-1157
Mailing Address - Street 1:270 CENTER DR
Mailing Address - Street 2:SUITE 120
Mailing Address - City:VERNON HILLS
Mailing Address - State:IL
Mailing Address - Zip Code:60061-1564
Mailing Address - Country:US
Mailing Address - Phone:847-573-1157
Mailing Address - Fax:224-513-5458
Practice Address - Street 1:270 CENTER DR
Practice Address - Street 2:SUITE 120
Practice Address - City:VERNON HILLS
Practice Address - State:IL
Practice Address - Zip Code:60061-1564
Practice Address - Country:US
Practice Address - Phone:847-573-1157
Practice Address - Fax:224-513-5458
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-14
Last Update Date:2014-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL016-004899213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL4932398OtherBCBSIL
ILV04047Medicare UPIN
IL5338400001Medicare NSC
IL211072Medicare ID - Type Unspecified