MEDICARE: SUPERIOR HEALTHCARE PHYSICAL MEDICINE OF WEST COUNTY, LLC

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	208100000X	Physical Medicine & Rehabilitation Physician		MO

General Provider Information

NPI Number	:	1467825224
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SUPERIOR HEALTHCARE PHYSICAL MEDICINE OF WEST COUNTY, LLC

Provider Business Mailing Address
First Line	:	2121 BARRETT STATION RD
Second Line	:
City	:	SAINT LOUIS
State	:	MO
Zip	:	63131-1606
Country	:	US
Telephone Number	:	314-394-1923
Fax Number	:

Provider Business Practice Location Address
First Line	:	2121 BARRETT STATION RD
Second Line	:
City	:	SAINT LOUIS
State	:	MO
Zip	:	63131-1606
Country	:	US
Telephone Number	:	314-394-1923
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	DR. DAN GOGLIOTTI
Credential	:	DC
Telephone Number	:	314-394-1923

Provider Enumeration Date	:	11/02/2015
Last Update Date	:	03/03/2023

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