1730296310 NPI number — MOORE ORTHOPAEDIC CLINIC, P.A.

Table of content: (NPI 1730296310)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1730296310 NPI number — MOORE ORTHOPAEDIC CLINIC, P.A.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MOORE ORTHOPAEDIC CLINIC, P.A.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1730296310
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 843384
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BOSTON
Provider Business Mailing Address State Name:
MA
Provider Business Mailing Address Postal Code:
02284-3384
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
803-227-8000
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
THE PLEX
Provider Second Line Business Practice Location Address:
741 FASHION DRIVE
Provider Business Practice Location Address City Name:
COLUMBIA
Provider Business Practice Location Address State Name:
SC
Provider Business Practice Location Address Postal Code:
29229
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
803-227-8005
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
08/23/2006

Additional Information

Authorized Official

Authorized Official Last Name:
MCNALLY
Authorized Official First Name:
SEAN
Authorized Official Middle Name:
Authorized Official Title or Position:
CEO
Authorized Official Telephone Number:
803-227-8152

Provider Taxonomy Codes

  • Taxonomy code: 207X00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: DM0194 . This is a "MEDICAID DME PROVIDER #" identifier , issued by the state of ( SC ) . This identifiers is of the category "OTHER".
  • Identifier: PA0686 , issued by the state of ( SC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 0497990001 . This is a "MEDICARE DMERC PROVIDER #" identifier , issued by the state of ( SC ) . This identifiers is of the category "OTHER".




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