Provider Demographics
NPI:1659552875
Name:MOORE DERMATOLOGY SC
Entity Type:Organization
Organization Name:MOORE DERMATOLOGY SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:JULIE
Authorized Official - Middle Name:A
Authorized Official - Last Name:MOORE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:708-450-5086
Mailing Address - Street 1:501 W NORTH AVE STE 103
Mailing Address - Street 2:
Mailing Address - City:MELROSE PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60160-1603
Mailing Address - Country:US
Mailing Address - Phone:708-450-5086
Mailing Address - Fax:708-345-4075
Practice Address - Street 1:501 W NORTH AVE STE 103
Practice Address - Street 2:
Practice Address - City:MELROSE PARK
Practice Address - State:IL
Practice Address - Zip Code:60160-1603
Practice Address - Country:US
Practice Address - Phone:708-450-5086
Practice Address - Fax:708-345-4075
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-15
Last Update Date:2021-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036075509207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL208854Medicare PIN
ILK05937Medicare PIN