Provider Demographics
NPI:1669484119
Name:OLYMPIC REHAB WELLNESS AND PAIN CENTER PC
Entity type:Organization
Organization Name:OLYMPIC REHAB WELLNESS AND PAIN CENTER PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ALEXANDER
Authorized Official - Middle Name:
Authorized Official - Last Name:BEYZER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:314-849-1003
Mailing Address - Street 1:10420 OLD OLIVE STREET RD STE 305
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63141-5914
Mailing Address - Country:US
Mailing Address - Phone:314-849-1003
Mailing Address - Fax:314-455-3469
Practice Address - Street 1:10420 OLD OLIVE STREET RD STE 305
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63141-5914
Practice Address - Country:US
Practice Address - Phone:314-849-1003
Practice Address - Fax:314-455-3469
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-13
Last Update Date:2024-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO111213208VP0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208VP0000XAllopathic & Osteopathic PhysiciansPain MedicinePain MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO507194207Medicaid
MO507194207Medicaid
MOMA1574Medicare PIN