Provider Demographics
NPI:1144389677
Name:MIDWEST PHYSICAL THERAPY, PC
Entity Type:Organization
Organization Name:MIDWEST PHYSICAL THERAPY, PC
Other - Org Name:MID-AMERICA PHYSICAL THERAPY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MAURY
Authorized Official - Middle Name:DUNCAN
Authorized Official - Last Name:ALLEN
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:877-870-4976
Mailing Address - Street 1:PO BOX 30110
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:MO
Mailing Address - Zip Code:65205-3110
Mailing Address - Country:US
Mailing Address - Phone:877-870-4976
Mailing Address - Fax:866-581-7732
Practice Address - Street 1:1926 OAK ST
Practice Address - Street 2:
Practice Address - City:UNIONVILLE
Practice Address - State:MO
Practice Address - Zip Code:63565-1180
Practice Address - Country:US
Practice Address - Phone:877-870-4976
Practice Address - Fax:866-581-7732
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-08
Last Update Date:2023-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20000174328225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO485883813Medicaid
MO485883813Medicaid
MO87123Medicare UPIN