Provider Demographics
NPI:1194702936
Name:MOSHER PHYSICAL THERAPY & SPORTS MEDICINE PC
Entity type:Organization
Organization Name:MOSHER PHYSICAL THERAPY & SPORTS MEDICINE PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:RUSSELL
Authorized Official - Middle Name:A
Authorized Official - Last Name:MOSHER
Authorized Official - Suffix:
Authorized Official - Credentials:MSPT
Authorized Official - Phone:757-789-3075
Mailing Address - Street 1:PO BOX 1059
Mailing Address - Street 2:
Mailing Address - City:ONLEY
Mailing Address - State:VA
Mailing Address - Zip Code:23418-1059
Mailing Address - Country:US
Mailing Address - Phone:757-331-4490
Mailing Address - Fax:757-331-4491
Practice Address - Street 1:712 RANDOLPH AVE
Practice Address - Street 2:
Practice Address - City:CAPE CHARLES
Practice Address - State:VA
Practice Address - Zip Code:23310-3308
Practice Address - Country:US
Practice Address - Phone:757-331-4490
Practice Address - Fax:757-331-4491
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-12-22
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA5088208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA147224OtherANTHEM BCBS
CD8647Medicare ID - Type Unspecified