Provider Demographics
NPI:1831467547
Name:MOORE, ELLIOT ROBERT (DPT)
Entity Type:Individual
Prefix:
First Name:ELLIOT
Middle Name:ROBERT
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 1:10776 GRAY'S CORNER RD., UNIT # 4
Mailing Address - Street 2:
Mailing Address - City:BERLIN
Mailing Address - State:MD
Mailing Address - Zip Code:21811-3561
Mailing Address - Country:US
Mailing Address - Phone:443-736-8554
Mailing Address - Fax:
Practice Address - Street 1:10776 GRAYS CORNER RD UNIT 4
Practice Address - Street 2:
Practice Address - City:BERLIN
Practice Address - State:MD
Practice Address - Zip Code:21811-3561
Practice Address - Country:US
Practice Address - Phone:410-641-2900
Practice Address - Fax:410-641-2914
Is Sole Proprietor?:No
Enumeration Date:2011-12-08
Last Update Date:2012-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist