MEDICARE: VITALITY MEDICAL CORP

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	207Q00000X	Family Medicine Physician	108125	MO

General Provider Information

NPI Number	:	1881900025
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	VITALITY MEDICAL CORP

Provider Business Mailing Address
First Line	:	9051 WATSON RD
Second Line	:	SUITE 343
City	:	SAINT LOUIS
State	:	MO
Zip	:	63126-2240
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	9051 WATSON RD
Second Line	:	SUITE 343
City	:	SAINT LOUIS
State	:	MO
Zip	:	63126-2240
Country	:	US
Telephone Number	:	314-556-5775
Fax Number	:

Authorized Official
Title or Position	:	CEO
Name	:	DREW SHOEMAKER
Credential	:
Telephone Number	:	314-556-5775

Provider Enumeration Date	:	08/25/2010
Last Update Date	:	08/25/2010

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Directions to “VITALITY MEDICAL CORP ” Practice Location

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