Provider Demographics
NPI:1588742514
Name:MOSES, EMMANUEL OLUMUYIWA (PT, DPT, OCS, CCI)
Entity type:Individual
Prefix:DR
First Name:EMMANUEL
Middle Name:OLUMUYIWA
Last Name:MOSES
Suffix:
Gender:M
Credentials:PT, DPT, OCS, CCI
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12150 ANNAPOLIS RD
Mailing Address - Street 2:SUITE 201
Mailing Address - City:GLENN DALE
Mailing Address - State:MD
Mailing Address - Zip Code:20769-9183
Mailing Address - Country:US
Mailing Address - Phone:301-352-8370
Mailing Address - Fax:301-352-8372
Practice Address - Street 1:12150 ANNAPOLIS RD
Practice Address - Street 2:SUITE 201
Practice Address - City:GLENN DALE
Practice Address - State:MD
Practice Address - Zip Code:20769
Practice Address - Country:US
Practice Address - Phone:301-352-8370
Practice Address - Fax:301-352-8372
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-01
Last Update Date:2018-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD21846225100000X, 2251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
No2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedicGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD045308100Medicaid
616235300OtherWORKERS COMPENSATION NUMBER