Provider Demographics
NPI:1578592903
Name:MOORE, TIMOTHY KEVIN (DC)
Entity Type:Individual
Prefix:DR
First Name:TIMOTHY
Middle Name:KEVIN
Last Name:MOORE
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:101 S MCLEAN BLVD STE A
Mailing Address - Street 2:
Mailing Address - City:SOUTH ELGIN
Mailing Address - State:IL
Mailing Address - Zip Code:60177-1830
Mailing Address - Country:US
Mailing Address - Phone:847-717-3400
Mailing Address - Fax:847-255-7945
Practice Address - Street 1:101 S MCLEAN BLVD STE A
Practice Address - Street 2:
Practice Address - City:SOUTH ELGIN
Practice Address - State:IL
Practice Address - Zip Code:60177-1830
Practice Address - Country:US
Practice Address - Phone:847-717-3400
Practice Address - Fax:847-255-7945
Is Sole Proprietor?:No
Enumeration Date:2006-06-30
Last Update Date:2019-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL038004893111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL4515230OtherBLUE CROSS BLUE SHIELD
IL038004893Medicaid
IL719140Medicare ID - Type Unspecified
ILT38108Medicare UPIN