Basic Information
| Provider Information | |||||||||
| NPI: | 1215120811 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MCQUILLAN | ||||||||
| FirstName: | MOIRA | ||||||||
| MiddleName: | E. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 12050 S HARLEM AVE | ||||||||
| Address2: | STE A | ||||||||
| City: | PALOS HEIGHTS | ||||||||
| State: | IL | ||||||||
| PostalCode: | 604632803 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7086711500 | ||||||||
| FaxNumber: | 7086711535 | ||||||||
| Practice Location | |||||||||
| Address1: | 10961 S KEDZIE AVE | ||||||||
| Address2: | |||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606552219 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7732399100 | ||||||||
| FaxNumber: | 7082296087 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/27/2007 | ||||||||
| LastUpdateDate: | 09/01/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/01/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 036-119095 | IL | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 036119095 | 01 | IL | STATE LICENSE | OTHER |