Provider Demographics
NPI:1497905327
Name:TUCKER, ROBERT SHAWN (PT)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:SHAWN
Last Name:TUCKER
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2558 S BRENTWOOD BLVD
Mailing Address - Street 2:#1 BRENTWOOD PHYSICAL THERAPY
Mailing Address - City:ST. LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63144
Mailing Address - Country:US
Mailing Address - Phone:314-961-8940
Mailing Address - Fax:314-961-8969
Practice Address - Street 1:2558 S BRENTWOOD BLVD
Practice Address - Street 2:#1 BRENTWOOD PHYSICAL THERAPY
Practice Address - City:ST. LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63144
Practice Address - Country:US
Practice Address - Phone:314-961-8940
Practice Address - Fax:314-961-8969
Is Sole Proprietor?:No
Enumeration Date:2008-09-29
Last Update Date:2008-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO113988225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
7477014OtherAETNA
231348OtherBC/BS
26-6569Medicare PIN