1699708495 NPI number — DOCTOR J M MORADIA MD SC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1699708495 NPI number — DOCTOR J M MORADIA MD SC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DOCTOR J M MORADIA MD SC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1699708495
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1600 DEMPSTER ST
Provider Second Line Business Mailing Address:
SUITE 207
Provider Business Mailing Address City Name:
PARK RIDGE
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60068
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
847-803-9393
Provider Business Mailing Address Fax Number:
847-803-1358

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1600 DEMPSTER ST
Provider Second Line Business Practice Location Address:
SUITE 207
Provider Business Practice Location Address City Name:
PARK RIDGE
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60068
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
847-803-9393
Provider Business Practice Location Address Fax Number:
847-803-1358
Provider Enumeration Date:
07/08/2006

Additional Information

Authorized Official

Authorized Official Last Name:
MORADIA
Authorized Official First Name:
JADAV
Authorized Official Middle Name:
M
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
847-803-9393

Provider Taxonomy Codes

  • Taxonomy code: 207R00000X , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 01627439 . This is a "BCBS" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".




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