1811218969 NPI number — MS. MEGAN MAUPIN BURGESS PT

Table of content: MS. MEGAN MAUPIN BURGESS PT (NPI 1811218969)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1811218969 NPI number — MS. MEGAN MAUPIN BURGESS PT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BURGESS
Provider First Name:
MEGAN
Provider Middle Name:
MAUPIN
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
PT
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1811218969
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/15/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 7412011
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CHICAGO
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60674-2011
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
314-286-1940
Provider Business Mailing Address Fax Number:
314-286-1473

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4240 DUNCAN AVE
Provider Second Line Business Practice Location Address:
DEPT PHYSICAL THERAPY, STE 120
Provider Business Practice Location Address City Name:
SAINT LOUIS
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
63110-1101
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
314-286-1940
Provider Business Practice Location Address Fax Number:
314-286-1473
Provider Enumeration Date:
06/11/2010

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 225100000X , with the licence number:  2010018434 , registered in the state of MO ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 480084011 , issued by the state of ( MO ) . This identifiers is of the category "MEDICAID".




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