Healthcare Provider Details

I. General information

NPI: 1164931960
Provider Name (Legal Business Name): MICHAEL MARTIN MCGUIRE PA-C, ATC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/25/2017
Last Update Date: 12/11/2025
Certification Date: 12/11/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

670 PIERCE BLVD STE 200
O FALLON IL
62269-2579
US

IV. Provider business mailing address

670 PIERCE BLVD
O FALLON IL
62269-2579
US

V. Phone/Fax

Practice location:
  • Phone: 618-206-2094
  • Fax:
Mailing address:
  • Phone: 618-206-2094
  • Fax: 618-607-5127

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number
License Number StateIN
# 2
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number003657-1
License Number StateNY
# 3
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number085.011631
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: