Provider Demographics
NPI:1144345471
Name:JACOB L. MOSKOVIC, M.D. S.C.
Entity type:Organization
Organization Name:JACOB L. MOSKOVIC, M.D. S.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JACOB
Authorized Official - Middle Name:L
Authorized Official - Last Name:MOSKOVIC
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:847-590-0050
Mailing Address - Street 1:120 W EASTMAN ST
Mailing Address - Street 2:SUITE 202
Mailing Address - City:ARLINGTON HEIGHTS
Mailing Address - State:IL
Mailing Address - Zip Code:60004-5937
Mailing Address - Country:US
Mailing Address - Phone:847-590-0050
Mailing Address - Fax:847-590-0080
Practice Address - Street 1:120 W EASTMAN ST
Practice Address - Street 2:SUITE 202
Practice Address - City:ARLINGTON HEIGHTS
Practice Address - State:IL
Practice Address - Zip Code:60004-5937
Practice Address - Country:US
Practice Address - Phone:847-590-0050
Practice Address - Fax:847-590-0080
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-19
Last Update Date:2009-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036040989101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL36040989Medicaid
IL36040989Medicaid
IL458920Medicare ID - Type Unspecified