Provider Demographics
NPI:1952406191
Name:RICK EDWARD ST. GEORGE
Entity Type:Organization
Organization Name:RICK EDWARD ST. GEORGE
Other - Org Name:ST GEORGE PHYSICAL THERAPY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:RICK
Authorized Official - Middle Name:EDWARD
Authorized Official - Last Name:ST GEORGE
Authorized Official - Suffix:
Authorized Official - Credentials:PT, OCS
Authorized Official - Phone:704-374-1811
Mailing Address - Street 1:1809 EAST BLVD
Mailing Address - Street 2:STE. 100
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28203-5914
Mailing Address - Country:US
Mailing Address - Phone:704-374-1811
Mailing Address - Fax:704-335-9958
Practice Address - Street 1:1809 EAST BLVD
Practice Address - Street 2:STE. 100
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28203-5914
Practice Address - Country:US
Practice Address - Phone:704-374-1811
Practice Address - Fax:704-335-9958
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-13
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC1839225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC250064Medicare ID - Type UnspecifiedMEDICARE PROVIDER #