MEDICARE: ELAINE WILDER PT

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	R0953	MO

General Provider Information

NPI Number	:	1821127812
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ELAINE WILDER PT

Provider Business Mailing Address
First Line	:	807 WAYFARER DR
Second Line	:
City	:	MANCHESTER
State	:	MO
Zip	:	63021-7523
Country	:	US
Telephone Number	:	314-977-8505
Fax Number	:	314-977-8513

Provider Business Practice Location Address
First Line	:	3437 CAROLINE ST
Second Line	:	ROOM 1015
City	:	SAINT LOUIS
State	:	MO
Zip	:	63104-1111
Country	:	US
Telephone Number	:	314-977-8538
Fax Number	:	314-977-8513

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

Provider Enumeration Date	:	03/05/2007
Last Update Date	:	07/08/2007

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Directions to “ ELAINE WILDER PT” Practice Location

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