Provider Demographics
NPI:1164829149
Name:ELECTRODIAGNOSTIC & REHAB MEDICINE
Entity Type:Organization
Organization Name:ELECTRODIAGNOSTIC & REHAB MEDICINE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/SECRETARY
Authorized Official - Prefix:
Authorized Official - First Name:AMY
Authorized Official - Middle Name:L
Authorized Official - Last Name:BELVILLE
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:816-233-9888
Mailing Address - Street 1:3107 FREDERICK AVE
Mailing Address - Street 2:SUITE C
Mailing Address - City:SAINT JOSEPH
Mailing Address - State:MO
Mailing Address - Zip Code:64506-2956
Mailing Address - Country:US
Mailing Address - Phone:816-233-9888
Mailing Address - Fax:816-233-0414
Practice Address - Street 1:3107 FREDERICK AVE
Practice Address - Street 2:SUITE C
Practice Address - City:SAINT JOSEPH
Practice Address - State:MO
Practice Address - Zip Code:64506-2956
Practice Address - Country:US
Practice Address - Phone:816-233-9888
Practice Address - Fax:816-233-0414
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-11-19
Last Update Date:2014-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2003013938204R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes204R00000XAllopathic & Osteopathic PhysiciansElectrodiagnostic MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOH86649Medicare UPIN
MO701C489Medicare PIN