Provider Demographics
NPI:1932392099
Name:MOORE, HENRY R III (MD)
Entity Type:Individual
Prefix:DR
First Name:HENRY
Middle Name:R
Last Name:MOORE
Suffix:III
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 1:611 W PARK ST
Mailing Address - Street 2:FAPC
Mailing Address - City:URBANA
Mailing Address - State:IL
Mailing Address - Zip Code:61801-2529
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:611 W PARK ST
Practice Address - Street 2:
Practice Address - City:URBANA
Practice Address - State:IL
Practice Address - Zip Code:61801-2529
Practice Address - Country:US
Practice Address - Phone:217-383-3240
Practice Address - Fax:217-383-4597
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-22
Last Update Date:2022-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCMD036123208600000X
IL036119986208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
0533210001OtherDMERC
IL036119986Medicaid
IL0533210001Medicare NSC
ILIL3270296Medicare PIN
IL036119986Medicaid
ILR03225Medicare PIN