MEDICARE: CHARLES B MCDONNELL PT, CHT

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	225100000X	Physical Therapist	01008	MO
2	2251H1200X	Hand Physical Therapist	9209001425	MO

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	P00165252	OTHER	MO	RAILROAD MEDICARE

General Provider Information

NPI Number	:	1427002476
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CHARLES B MCDONNELL PT, CHT

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

Provider Business Practice Location Address
First Line	:	4800 MEXICO RD
Second Line	:	SUITE 104
City	:	ST PETERS
State	:	MO
Zip	:	63376-1666
Country	:	US
Telephone Number	:	636-939-9540
Fax Number	:	636-939-9886

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

Provider Enumeration Date	:	05/22/2006
Last Update Date	:	09/11/2012

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