Provider Demographics
NPI:1851549182
Name:PODGORNY, JOELLE RUTH (PT, MSPT)
Entity Type:Individual
Prefix:
First Name:JOELLE
Middle Name:RUTH
Last Name:PODGORNY
Suffix:
Gender:F
Credentials:PT, MSPT
Other - Prefix:
Other - First Name:JOELLE
Other - Middle Name:RUTH
Other - Last Name:JONES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:763 S. NEW BALLAS RD #200
Mailing Address - Street 2:200
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63141-8711
Mailing Address - Country:US
Mailing Address - Phone:314-991-2562
Mailing Address - Fax:314-991-2593
Practice Address - Street 1:763 S. NEW BALLAS RD #200
Practice Address - Street 2:200
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63141-8711
Practice Address - Country:US
Practice Address - Phone:314-991-2562
Practice Address - Fax:314-991-2593
Is Sole Proprietor?:No
Enumeration Date:2008-08-28
Last Update Date:2012-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO105439225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO266649Medicare Oscar/Certification