Provider Demographics
NPI:1417960758
Name:MORAN, GEORGE GAW (MD)
Entity Type:Individual
Prefix:
First Name:GEORGE
Middle Name:GAW
Last Name:MORAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:5201 S WILLOW SPRINGS RD
Mailing Address - Street 2:SUITE 380
Mailing Address - City:LAGRANGE
Mailing Address - State:IL
Mailing Address - Zip Code:60525-6537
Mailing Address - Country:US
Mailing Address - Phone:708-354-2550
Mailing Address - Fax:708-354-4552
Practice Address - Street 1:5201 WILLOW SPRINGS RD
Practice Address - Street 2:SUITE 380
Practice Address - City:LA GRANGE HIGHLANDS
Practice Address - State:IL
Practice Address - Zip Code:60525-6537
Practice Address - Country:US
Practice Address - Phone:708-354-2550
Practice Address - Fax:708-354-4552
Is Sole Proprietor?:No
Enumeration Date:2006-08-15
Last Update Date:2011-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-057691208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036057691Medicaid
IL036057691Medicaid
ILC43244Medicare UPIN
214706025Medicare PIN