Healthcare Provider Details

I. General information

NPI: 1194702936
Provider Name (Legal Business Name): MOSHER PHYSICAL THERAPY & SPORTS MEDICINE PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/22/2005
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

712 RANDOLPH AVE
CAPE CHARLES VA
23310-3308
US

IV. Provider business mailing address

PO BOX 1059
ONLEY VA
23418-1059
US

V. Phone/Fax

Practice location:
  • Phone: 757-331-4490
  • Fax: 757-331-4491
Mailing address:
  • Phone: 757-331-4490
  • Fax: 757-331-4491

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number5088
License Number StateVA

VIII. Authorized Official

Name: MR. RUSSELL A MOSHER
Title or Position: PRESIDENT OWNER
Credential: MSPT
Phone: 757-789-3075