Provider Demographics
NPI:1508162660
Name:MOORE, GREGORY M (DPT)
Entity Type:Individual
Prefix:DR
First Name:GREGORY
Middle Name:M
Last Name:MOORE
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:33900 HARPER AVE STE 104
Mailing Address - Street 2:
Mailing Address - City:CLINTON TWP
Mailing Address - State:MI
Mailing Address - Zip Code:48035-4258
Mailing Address - Country:US
Mailing Address - Phone:586-350-2644
Mailing Address - Fax:
Practice Address - Street 1:37367 6 MILE RD
Practice Address - Street 2:
Practice Address - City:LIVONIA
Practice Address - State:MI
Practice Address - Zip Code:48152-2775
Practice Address - Country:US
Practice Address - Phone:734-402-2335
Practice Address - Fax:734-402-2338
Is Sole Proprietor?:No
Enumeration Date:2011-02-07
Last Update Date:2023-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI55010154822251X0800X, 225100000X, 2251S0007X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic
No2251S0007XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistSports
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIN69750069Medicare PIN
MIMI6211021Medicare PIN