MEDICARE: MR. RICK E ST GEORGE PT, OCS

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	1839	NC

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	07932	OTHER	NC	BCBSNC PROVIDER #

General Provider Information

NPI Number	:	1588621635
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. RICK E ST GEORGE PT, OCS

Provider Business Mailing Address
First Line	:	4115 ARBOR WAY
Second Line	:
City	:	CHARLOTTE
State	:	NC
Zip	:	28211-3805
Country	:	US
Telephone Number	:	704-607-1758
Fax Number	:

Provider Business Practice Location Address
First Line	:	1809 EAST BLVD
Second Line	:	SUITE 100
City	:	CHARLOTTE
State	:	NC
Zip	:	28203-5879
Country	:	US
Telephone Number	:	704-374-1811
Fax Number	:

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

Provider Enumeration Date	:	05/01/2006
Last Update Date	:	07/08/2007

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