MEDICARE: PATRICIA MCCLURG PTA

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	2013018938	MO

General Provider Information

NPI Number	:	1578969713
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	PATRICIA MCCLURG PTA

Provider Business Mailing Address
First Line	:	925 S SARAH ST
Second Line	:
City	:	SAINT LOUIS
State	:	MO
Zip	:	63110-1741
Country	:	US
Telephone Number	:	918-625-4139
Fax Number	:

Provider Business Practice Location Address
First Line	:	13610 BARRETT OFFICE DR
Second Line	:	SUITE 104
City	:	BALLWIN
State	:	MO
Zip	:	63021-7816
Country	:	US
Telephone Number	:	314-822-5107
Fax Number	:

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

Provider Enumeration Date	:	11/17/2014
Last Update Date	:	11/17/2014

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