MEDICARE: JOHN ROBERT MOYNIHAN DPT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225100000X	Physical Therapist	070.028378	IL
2	225100000X	Physical Therapist	16291-24	WI

General Provider Information

NPI Number	:	1295419497
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JOHN ROBERT MOYNIHAN DPT

Provider Business Mailing Address
First Line	:	33900 HARPER AVE STE 104
Second Line	:
City	:	CLINTON TWP
State	:	MI
Zip	:	48035-4258
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	315 E NORTHWEST HWY
Second Line	:
City	:	PALATINE
State	:	IL
Zip	:	60067-8116
Country	:	US
Telephone Number	:	847-701-1930
Fax Number	:	847-701-1931

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/09/2023
Last Update Date	:	07/02/2024

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