1700415171 NPI number — CHARLES H. EDWARDS PHYSICAL THERAPIST

Table of content: CHARLES H. EDWARDS PHYSICAL THERAPIST (NPI 1700415171)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1700415171 NPI number — CHARLES H. EDWARDS PHYSICAL THERAPIST

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
EDWARDS
Provider First Name:
CHARLES
Provider Middle Name:
H.
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PHYSICAL THERAPIST
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:
1700415171
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/07/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
308 OLD FORESTER DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
O FALLON
Provider Business Mailing Address State Name:
MO
Provider Business Mailing Address Postal Code:
63367-4045
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
816-294-3070
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
224 SOUTH WOODS MILLRD.
Provider Second Line Business Practice Location Address:
SUITE 610 SOUTH
Provider Business Practice Location Address City Name:
CHESTERFIELD
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
63017
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
314-205-6551
Provider Business Practice Location Address Fax Number:
314-576-2371
Provider Enumeration Date:
04/07/2020

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:  00578 , 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)





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