Provider Demographics
NPI:1063466019
Name:WEBER, NICHOLAS (MPT)
Entity Type:Individual
Prefix:
First Name:NICHOLAS
Middle Name:
Last Name:WEBER
Suffix:
Gender:M
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:607 DEWEY AVE NW
Mailing Address - Street 2:STE 300
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49504-7335
Mailing Address - Country:US
Mailing Address - Phone:616-356-5000
Mailing Address - Fax:616-356-5001
Practice Address - Street 1:4800 MEXICO RD
Practice Address - Street 2:SUITE 104
Practice Address - City:SAINT PETERS
Practice Address - State:MO
Practice Address - Zip Code:63376-1666
Practice Address - Country:US
Practice Address - Phone:636-939-9540
Practice Address - Fax:636-939-9886
Is Sole Proprietor?:No
Enumeration Date:2006-05-22
Last Update Date:2016-05-12
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MO2005017285225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO11543068OtherCAQH
MOP00388087OtherRAILROAD MEDICARE
MO220301643Medicare PIN