Provider Demographics
NPI:1730296310
Name:MOORE ORTHOPAEDIC CLINIC, P.A.
Entity Type:Organization
Organization Name:MOORE ORTHOPAEDIC CLINIC, P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:SEAN
Authorized Official - Middle Name:
Authorized Official - Last Name:MCNALLY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:803-227-8152
Mailing Address - Street 1:PO BOX 843384
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02284-3384
Mailing Address - Country:US
Mailing Address - Phone:803-227-8000
Mailing Address - Fax:
Practice Address - Street 1:THE PLEX
Practice Address - Street 2:741 FASHION DRIVE
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29229
Practice Address - Country:US
Practice Address - Phone:803-227-8005
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-23
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCDM0194OtherMEDICAID DME PROVIDER #
SCPA0686Medicaid
SC0497990001OtherMEDICARE DMERC PROVIDER #
SC=========OtherFEDERAL TAX ID#
SCPA0686Medicaid