Healthcare Provider Details

I. General information

NPI: 1104157320
Provider Name (Legal Business Name): LAURA A SHIMKUS DPT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/28/2010
Last Update Date: 03/01/2022
Certification Date: 03/01/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2900 FRANK SCOTT PKWY W STE 928
BELLEVILLE IL
62223-5000
US

IV. Provider business mailing address

2900 FRANK SCOTT PKWY W STE 928
BELLEVILLE IL
62223-5000
US

V. Phone/Fax

Practice location:
  • Phone: 618-234-9705
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number070017597
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: