Provider Demographics
NPI:1609930593
Name:EXCEL PHYSICAL THERAPY & SPORTS MEDICINE CLINIC
Entity Type:Organization
Organization Name:EXCEL PHYSICAL THERAPY & SPORTS MEDICINE CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JILL
Authorized Official - Middle Name:S
Authorized Official - Last Name:MCCORMICK
Authorized Official - Suffix:
Authorized Official - Credentials:PT, ATC
Authorized Official - Phone:773-892-7501
Mailing Address - Street 1:1420 W ASHLEY RD
Mailing Address - Street 2:
Mailing Address - City:BOONVILLE
Mailing Address - State:MO
Mailing Address - Zip Code:65233-2112
Mailing Address - Country:US
Mailing Address - Phone:660-882-6115
Mailing Address - Fax:660-882-6120
Practice Address - Street 1:1420 W ASHLEY RD
Practice Address - Street 2:
Practice Address - City:BOONVILLE
Practice Address - State:MO
Practice Address - Zip Code:65233-2112
Practice Address - Country:US
Practice Address - Phone:660-882-6115
Practice Address - Fax:660-882-6120
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-21
Last Update Date:2007-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO108639225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
122566OtherBLUE CROSS BLUE SHEILD
MODA1611OtherMEDICARE RAILROAD
990001685Medicare PIN