Provider Demographics
NPI:1730434879
Name:MOORE, MARY ELLEN (DO)
Entity type:Individual
Prefix:
First Name:MARY ELLEN
Middle Name:
Last Name:MOORE
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:4140 SOUTHWEST HWY
Mailing Address - Street 2:
Mailing Address - City:HOMETOWN
Mailing Address - State:IL
Mailing Address - Zip Code:60456-1135
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4301 W 95TH ST STE 1
Practice Address - Street 2:
Practice Address - City:OAK LAWN
Practice Address - State:IL
Practice Address - Zip Code:60453-2698
Practice Address - Country:US
Practice Address - Phone:708-425-5500
Practice Address - Fax:708-425-0771
Is Sole Proprietor?:No
Enumeration Date:2012-07-15
Last Update Date:2021-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL125.061971207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine