Provider Demographics
NPI:1275615544
Name:EVERSON ORTHOPEDIC, PC
Entity Type:Organization
Organization Name:EVERSON ORTHOPEDIC, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICAL THERAPIST/OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:SHAWN
Authorized Official - Middle Name:K
Authorized Official - Last Name:EVERSON
Authorized Official - Suffix:
Authorized Official - Credentials:MHS, PT, OCS, MTC
Authorized Official - Phone:314-991-2562
Mailing Address - Street 1:763 S NEW BALLAS RD
Mailing Address - Street 2:#200
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63141-8704
Mailing Address - Country:US
Mailing Address - Phone:314-991-2562
Mailing Address - Fax:
Practice Address - Street 1:763 S NEW BALLAS RD
Practice Address - Street 2:#200
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63141-8704
Practice Address - Country:US
Practice Address - Phone:314-991-2562
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-19
Last Update Date:2008-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO01532225100000X
MO00423225100000X
MO2005035740225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
No225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy AssistantGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
990001792Medicare PIN