Provider Demographics
NPI:1558351312
Name:MOEN, MICHAEL D (MD)
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:D
Last Name:MOEN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1875 DEMPSTER ST
Mailing Address - Street 2:SUITE 665
Mailing Address - City:PARK RIDGE
Mailing Address - State:IL
Mailing Address - Zip Code:60068-1186
Mailing Address - Country:US
Mailing Address - Phone:847-825-1590
Mailing Address - Fax:847-825-1604
Practice Address - Street 1:1875 DEMPSTER ST
Practice Address - Street 2:SUITE 665
Practice Address - City:PARK RIDGE
Practice Address - State:IL
Practice Address - Zip Code:60068
Practice Address - Country:US
Practice Address - Phone:847-825-1590
Practice Address - Fax:847-825-1604
Is Sole Proprietor?:No
Enumeration Date:2005-10-24
Last Update Date:2018-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036083401207VG0400X
IL036-083401207VF0040X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VF0040XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyUrogynecology and Reconstructive Pelvic Surgery
No207VG0400XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036083401Medicaid