Provider Demographics
NPI:1912914490
Name:MOORE, MONICA ANNETTE (MD)
Entity Type:Individual
Prefix:DR
First Name:MONICA
Middle Name:ANNETTE
Last Name:MOORE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9119 S EXCHANGE AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60617-4225
Mailing Address - Country:US
Mailing Address - Phone:773-768-5000
Mailing Address - Fax:773-768-6153
Practice Address - Street 1:41 E 8TH ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60605-2168
Practice Address - Country:US
Practice Address - Phone:312-212-9000
Practice Address - Fax:312-212-9003
Is Sole Proprietor?:No
Enumeration Date:2006-08-01
Last Update Date:2016-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-096183207VG0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VG0400XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036-096183Medicaid
IL36-4454907OtherMAM MD CORP TIN
IL36-4454907OtherMAM MD CORP TIN
ILK37695Medicare Oscar/Certification
IL997080Medicare ID - Type Unspecified