Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207YS0123X | Facial Plastic Surgeon | 036-104040 | IL |
NPI | 1548342355 |
---|---|
Provider Name | Dr. George Thomas Moynihan |
First Address | Chicago, IL 60611-2740 |
Second Address | Chicago, IL 60611-2740 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 20/10/2006 |
Last Update Date | 29/04/2014 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
H92062 | (02) | IL |