MEDICARE: LOGAN GEGG P.T.A

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225200000X	Physical Therapy Assistant	2016025040	MO

General Provider Information

NPI Number	:	1013450691
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LOGAN GEGG P.T.A

Provider Business Mailing Address
First Line	:	19536 STATE RTE N
Second Line	:
City	:	SAINT MARY
State	:	MO
Zip	:	63673-9002
Country	:	US
Telephone Number	:	573-535-1407
Fax Number	:

Provider Business Practice Location Address
First Line	:	19536 STATE RTE N
Second Line	:
City	:	SAINT MARY
State	:	MO
Zip	:	63673-9002
Country	:	US
Telephone Number	:	573-535-1407
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/30/2016
Last Update Date	:	11/30/2016

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Directions to “ LOGAN GEGG P.T.A” Practice Location

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