1609852722 NPI number — MS. KELLY J MOYER M.S., C.G.C.

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 1609852722 NPI number — MS. KELLY J MOYER M.S., C.G.C.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MOYER
Provider First Name:
KELLY
Provider Middle Name:
J
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
M.S., C.G.C.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
CONNERTON-MOYER
Provider Other First Name:
KELLY
Provider Other Middle Name:
J
Provider Other Name Prefix Text:
MS.
Provider Other Name Suffix Text:
Provider Other Credential Text:
M.S., C.G.C.
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1609852722
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1152 S GROVE AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
OAK PARK
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60304-1941
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
708-445-9917
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2160 SOUTH FIRST AVE
Provider Second Line Business Practice Location Address:
RM.1024/BUILD 103 - OB/GYN, LUMC
Provider Business Practice Location Address City Name:
MAYWOOD
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60153
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
708-216-8167
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
12/20/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 170300000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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