Provider Demographics
NPI:1033422902
Name:MOORE, MICHAEL RYAN (DPT)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:RYAN
Last Name:MOORE
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:628TH MEDICAL GROUP
Mailing Address - Street 2:204 WEST HILL BLVD
Mailing Address - City:CHARLESTON
Mailing Address - State:SC
Mailing Address - Zip Code:29404
Mailing Address - Country:US
Mailing Address - Phone:804-571-5000
Mailing Address - Fax:804-518-1314
Practice Address - Street 1:628TH MEDICAL GROUP
Practice Address - Street 2:204 WEST HILL BLVD
Practice Address - City:CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29404
Practice Address - Country:US
Practice Address - Phone:804-571-5000
Practice Address - Fax:804-518-1314
Is Sole Proprietor?:No
Enumeration Date:2010-07-21
Last Update Date:2018-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2305206565225100000X
SC8765225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA0603180002Medicare NSC