MEDICARE: JODIE RAE SHUH MOT

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	171W00000X	Contractor	2006003000	MO

General Provider Information

NPI Number	:	1699811984
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JODIE RAE SHUH MOT

Provider Business Mailing Address
First Line	:	1421 ORIOLE PL
Second Line	:
City	:	BRENTWOOD
State	:	MO
Zip	:	63144-1126
Country	:	US
Telephone Number	:	573-225-2168
Fax Number	:	636-928-2862

Provider Business Practice Location Address
First Line	:	2561 ABBYDALE DR
Second Line	:
City	:	SAINT CHARLES
State	:	MO
Zip	:	63303-3018
Country	:	US
Telephone Number	:	636-928-3760
Fax Number	:	636-928-2862

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

Provider Enumeration Date	:	01/30/2007
Last Update Date	:	03/06/2008

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