MEDICARE: MOSHER PHYSICAL THERAPY AND SPORTSMEDICINE INC

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	208100000X	Physical Medicine & Rehabilitation Physician	0380	VA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	278177	OTHER	VA	ANTHEM BCBS

General Provider Information

NPI Number	:	1629055462
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MOSHER PHYSICAL THERAPY AND SPORTSMEDICINE INC

Provider Business Mailing Address
First Line	:	PO BOX 1059
Second Line	:
City	:	ONLEY
State	:	VA
Zip	:	23418
Country	:	US
Telephone Number	:	757-789-3075
Fax Number	:	757-789-3306

Provider Business Practice Location Address
First Line	:	20435 WASHINGTON ST
Second Line	:
City	:	ONLEY
State	:	VA
Zip	:	23418
Country	:	US
Telephone Number	:	757-789-3075
Fax Number	:	757-789-3306

Authorized Official
Title or Position	:	OWNER
Name	:	MRS. DANIELLE MOSHER
Credential	:	MSPT
Telephone Number	:	757-789-3075

Provider Enumeration Date	:	12/22/2005
Last Update Date	:	08/27/2010

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