Provider Demographics
NPI:1295715886
Name:PHYSICAL MEDICINE & REHABILITATION CLINIC OF ST. LOUIS LLC
Entity type:Organization
Organization Name:PHYSICAL MEDICINE & REHABILITATION CLINIC OF ST. LOUIS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:L
Authorized Official - Last Name:WILLIAMS
Authorized Official - Suffix:II
Authorized Official - Credentials:MD
Authorized Official - Phone:314-390-6789
Mailing Address - Street 1:121 SAINT LUKES CENTER DR
Mailing Address - Street 2:STE. 500
Mailing Address - City:CHESTERFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:63017-3509
Mailing Address - Country:US
Mailing Address - Phone:314-390-6789
Mailing Address - Fax:314-469-4797
Practice Address - Street 1:121 SAINT LUKES CENTER DR
Practice Address - Street 2:STE. 500
Practice Address - City:CHESTERFIELD
Practice Address - State:MO
Practice Address - Zip Code:63017-3509
Practice Address - Country:US
Practice Address - Phone:314-205-6503
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-01-19
Last Update Date:2022-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO500577507Medicaid
MODE9054OtherMEDICARE RAILROAD
MO500577507Medicaid