Provider Demographics
NPI:1548342355
Name:MOYNIHAN, GEORGE THOMAS (MD)
Entity type:Individual
Prefix:DR
First Name:GEORGE
Middle Name:THOMAS
Last Name:MOYNIHAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1 E ERIE ST
Mailing Address - Street 2:SUITE 640
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60611-2740
Mailing Address - Country:US
Mailing Address - Phone:312-988-9300
Mailing Address - Fax:312-988-9310
Practice Address - Street 1:1 E ERIE ST
Practice Address - Street 2:SUITE 640
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60611-2740
Practice Address - Country:US
Practice Address - Phone:312-988-9300
Practice Address - Fax:312-988-9310
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-20
Last Update Date:2014-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-104040207YS0123X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207YS0123XAllopathic & Osteopathic PhysiciansOtolaryngologyFacial Plastic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILH92062Medicare UPIN
IL210428Medicare ID - Type Unspecified