Healthcare Provider Details

I. General information

NPI: 1033422902
Provider Name (Legal Business Name): MICHAEL RYAN MOORE DPT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/21/2010
Last Update Date: 12/10/2025
Certification Date: 12/10/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

628TH MEDICAL GROUP 204 WEST HILL BLVD
CHARLESTON SC
29404
US

IV. Provider business mailing address

2001 BUTTERFIELD RD STE 1600
DOWNERS GROVE IL
60515-1211
US

V. Phone/Fax

Practice location:
  • Phone: 804-571-5000
  • Fax: 804-518-1314
Mailing address:
  • Phone: 866-370-8206
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number2305206565
License Number StateVA
# 2
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number8765
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: