Healthcare Provider Details

I. General information

NPI: 1972410488
Provider Name (Legal Business Name): SYDNEY MOORE DPT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/27/2026
Last Update Date: 08/27/2026
Certification Date: 08/27/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

916 TALON DR
O FALLON IL
62269-1848
US

IV. Provider business mailing address

802 W MADISON ST
O FALLON IL
62269-1030
US

V. Phone/Fax

Practice location:
  • Phone: 618-628-8211
  • Fax: 618-628-0883
Mailing address:
  • Phone: 618-628-8211
  • Fax: 618-628-0883

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number070.040678
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: