Provider Demographics
NPI:1467565929
Name:PEROUTKA, WILLIAM G JR (MPT, ATC)
Entity Type:Individual
Prefix:MR
First Name:WILLIAM
Middle Name:G
Last Name:PEROUTKA
Suffix:JR
Gender:M
Credentials:MPT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:939 HIGHWAY K
Mailing Address - Street 2:
Mailing Address - City:O FALLON
Mailing Address - State:MO
Mailing Address - Zip Code:63366-2910
Mailing Address - Country:US
Mailing Address - Phone:636-240-7000
Mailing Address - Fax:636-240-7513
Practice Address - Street 1:939 HIGHWAY K
Practice Address - Street 2:
Practice Address - City:O FALLON
Practice Address - State:MO
Practice Address - Zip Code:63366-2910
Practice Address - Country:US
Practice Address - Phone:636-240-7000
Practice Address - Fax:636-240-7513
Is Sole Proprietor?:No
Enumeration Date:2006-08-17
Last Update Date:2008-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2001007779225100000X
MO20010140382255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer