Provider Demographics
NPI:1376753335
Name:PETEREIT, WAYNE E (LPT)
Entity Type:Individual
Prefix:MR
First Name:WAYNE
Middle Name:E
Last Name:PETEREIT
Suffix:
Gender:M
Credentials:LPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2127 INNERBELT BUSINESS CENTER DR
Mailing Address - Street 2:SUITE 107
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63114-5700
Mailing Address - Country:US
Mailing Address - Phone:314-506-8850
Mailing Address - Fax:
Practice Address - Street 1:1201 S MAIN ST
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:IL
Practice Address - Zip Code:62650-3339
Practice Address - Country:US
Practice Address - Phone:217-479-2300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-22
Last Update Date:2016-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
225100000X
IL070-004624225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL070004624OtherLICENSED PHYSICAL THERAPI