Active NPI
Justin Richardson Moore, MD
- Student in an Organized Health Care Education/Training Program
- Chicago, IL
National Provider Identifier
1104679059
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Student in an Organized Health Care Education/Training Program
- Practice address
- 1901 W Harrison St
Chicago, IL 60612-3714 - Phone
- (312) 864-6000
- NPI assigned
- Apr 10, 2024
- Sex
- Male
- Sole proprietor
- No
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 2
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Student in an Organized Health Care Education/Training Program | 390200000X | Primary | ||
| Family Medicine Physician | 207Q00000X | 125.085396 | IL |
Addresses
Primary practice location
1901 W Harrison St
Chicago, IL 60612-3714
Mailing address
1901 W Harrison St
Chicago, IL 60612-3714
Phone (312) 864-6000
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Enrolled in IL
- Eligible to order & refer
- Part B services: Yes
- Medical equipment: Yes
- Home health: Yes
- Power mobility devices: Yes
- Hospice: Yes
Enrollment records 1
| Enrollment ID | State | Provider type | PAC ID | Details |
|---|---|---|---|---|
| I20250516001062 | IL | Order and Referring Only - Family Practice | 6103344809 |
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Enrolled
- Credentials
- Doctor of Medicine
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 125.085396 | IL | MD | Family Medicine Physician |
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1712707200000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1746921600000",
"number": "1104679059",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "1901 W HARRISON ST",
"city": "CHICAGO",
"state": "IL",
"postal_code": "606123714",
"telephone_number": "312-864-6000"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "1901 W HARRISON ST",
"city": "CHICAGO",
"state": "IL",
"postal_code": "606123714",
"telephone_number": "312-864-6000"
}
],
"practiceLocations": [],
"basic": {
"last_name": "MOORE",
"first_name": "JUSTIN",
"middle_name": "RICHARDSON",
"credential": "MD",
"sole_proprietor": "NO",
"sex": "M",
"enumeration_date": "2024-04-10",
"last_updated": "2025-05-11",
"certification_date": "2025-05-11",
"status": "A"
},
"taxonomies": [
{
"code": "390200000X",
"taxonomy_group": "",
"desc": "Student in an Organized Health Care Education/Training Program",
"state": null,
"license": null,
"primary": true
},
{
"code": "207Q00000X",
"taxonomy_group": "",
"desc": "Family Medicine",
"state": "IL",
"license": "125.085396",
"primary": false
}
],
"identifiers": [],
"endpoints": [],
"other_names": []
}Other providers in Chicago, IL
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on May 11, 2025; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments; Order and Referring.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.