Basic Information
| Provider Information | |||||||||
| NPI: | 1598702912 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MOSHOVITIS | ||||||||
| FirstName: | CARL | ||||||||
| MiddleName: | K | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5140 N. CLAIFORNIA AVE. | ||||||||
| Address2: | SUITE 780-GMP | ||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606253657 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7739893957 | ||||||||
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| Practice Location | |||||||||
| Address1: | 5140 N. CALIFORNIA AVE. | ||||||||
| Address2: | SUITE 780-GMP | ||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 60625 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7739893957 | ||||||||
| FaxNumber: | 7739893971 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/02/2006 | ||||||||
| LastUpdateDate: | 05/07/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 04/12/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RC0000X | 036077963 | IL | N | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease | 207RI0011X | 036077963 | IL | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Interventional Cardiology |
ID Information
| ID | Type | State | Issuer | Description | 036077963 | 05 | IL | MEDICAID |