Provider Demographics
NPI:1427002476
Name:MCDONNELL, CHARLES B (PT, CHT)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:B
Last Name:MCDONNELL
Suffix:
Gender:M
Credentials:PT, CHT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2454 W CLAY ST
Mailing Address - Street 2:
Mailing Address - City:SAINT CHARLES
Mailing Address - State:MO
Mailing Address - Zip Code:63301-2548
Mailing Address - Country:US
Mailing Address - Phone:636-916-4625
Mailing Address - Fax:636-916-4628
Practice Address - Street 1:4800 MEXICO RD
Practice Address - Street 2:SUITE 104
Practice Address - City:ST 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:2012-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO01008225100000X
MO92090014252251H1200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No2251H1200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistHand
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOP00165252OtherRAILROAD MEDICARE
MO990201643Medicare PIN