Provider Demographics
NPI:1821001918
Name:PROFESSIONAL CARE PROVIDERS, LLC
Entity Type:Organization
Organization Name:PROFESSIONAL CARE PROVIDERS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:RAY
Authorized Official - Middle Name:
Authorized Official - Last Name:BARTLETT
Authorized Official - Suffix:
Authorized Official - Credentials:PA
Authorized Official - Phone:636-577-1357
Mailing Address - Street 1:2025 ZUMBEHL RD
Mailing Address - Street 2:#45
Mailing Address - City:SAINT CHARLES
Mailing Address - State:MO
Mailing Address - Zip Code:63303-2723
Mailing Address - Country:US
Mailing Address - Phone:636-577-1357
Mailing Address - Fax:636-447-1202
Practice Address - Street 1:723 1ST CAPITOL DR
Practice Address - Street 2:
Practice Address - City:SAINT CHARLES
Practice Address - State:MO
Practice Address - Zip Code:63301-2729
Practice Address - Country:US
Practice Address - Phone:636-577-1357
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-13
Last Update Date:2008-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO33327207R00000X
MO104933363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Single Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MODE8055OtherRAILROAD MEDICARE
MODE8055OtherRAILROAD MEDICARE