Provider Demographics
NPI:1720766629
Name:KOMIC, MUHAREM (MAT, PES)
Entity Type:Individual
Prefix:
First Name:MUHAREM
Middle Name:
Last Name:KOMIC
Suffix:
Gender:M
Credentials:MAT, PES
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:419 W RIPA AVE
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63125-2740
Mailing Address - Country:US
Mailing Address - Phone:314-680-9031
Mailing Address - Fax:
Practice Address - Street 1:210 LINDSEY WILSON ST
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:KY
Practice Address - Zip Code:42728-1223
Practice Address - Country:US
Practice Address - Phone:800-264-0138
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-07-10
Last Update Date:2023-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer