1427002476 NPI number — CHARLES B MCDONNELL PT, CHT

Table of content: CHARLES B MCDONNELL PT, CHT (NPI 1427002476)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1427002476 NPI number — CHARLES B MCDONNELL PT, CHT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MCDONNELL
Provider First Name:
CHARLES
Provider Middle Name:
B
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PT, CHT
Provider Gender Code:
M

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:
1427002476
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/11/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2454 W CLAY ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SAINT CHARLES
Provider Business Mailing Address State Name:
MO
Provider Business Mailing Address Postal Code:
63301-2548
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
636-916-4625
Provider Business Mailing Address Fax Number:
636-916-4628

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4800 MEXICO RD
Provider Second Line Business Practice Location Address:
SUITE 104
Provider Business Practice Location Address City Name:
ST PETERS
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
63376-1666
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
636-939-9540
Provider Business Practice Location Address Fax Number:
636-939-9886
Provider Enumeration Date:
05/22/2006

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:  01008 , registered in the state of MO ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 2251H1200X , with the licence number: 9209001425 , registered in the state of MO ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: P00165252 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( MO ) . This identifiers is of the category "OTHER".




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