Provider Demographics
NPI:1750670808
Name:EVELYN MARIE MOORE O.D., P.C.
Entity Type:Organization
Organization Name:EVELYN MARIE MOORE O.D., P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT OF CORPORATION
Authorized Official - Prefix:DR
Authorized Official - First Name:EVELYN
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:MOORE
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:217-351-4106
Mailing Address - Street 1:501 S MATTIS AVE
Mailing Address - Street 2:SUITE B
Mailing Address - City:CHAMPAIGN
Mailing Address - State:IL
Mailing Address - Zip Code:61821-4274
Mailing Address - Country:US
Mailing Address - Phone:217-351-4106
Mailing Address - Fax:217-351-4052
Practice Address - Street 1:501 S MATTIS AVE
Practice Address - Street 2:SUITE B
Practice Address - City:CHAMPAIGN
Practice Address - State:IL
Practice Address - Zip Code:61821-4274
Practice Address - Country:US
Practice Address - Phone:217-351-4106
Practice Address - Fax:217-351-4052
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-03-29
Last Update Date:2011-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL046006881332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1497826655Medicaid
IL65910Medicare UPIN
IL1497826655Medicaid
IL1497826655Medicare PIN