Provider Demographics
NPI:1487755518
Name:MOOD, GIRISH R (MD)
Entity type:Individual
Prefix:
First Name:GIRISH
Middle Name:R
Last Name:MOOD
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:340 W LINCOLN ST
Mailing Address - Street 2:SUITE 400
Mailing Address - City:BELLEVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62220-1900
Mailing Address - Country:US
Mailing Address - Phone:618-233-6044
Mailing Address - Fax:
Practice Address - Street 1:340 W LINCOLN ST
Practice Address - Street 2:SUITE 400
Practice Address - City:BELLEVILLE
Practice Address - State:IL
Practice Address - Zip Code:62220-1900
Practice Address - Country:US
Practice Address - Phone:618-233-6044
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-25
Last Update Date:2022-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35086063207RC0000X
IL036133156207RC0000X
KYTP573207RC0000X
ND14145207RI0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional Cardiology
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN201320850Medicaid
KY7100360210Medicaid
OH2586705Medicaid
OH2586705Medicaid
KY7100360210Medicaid