Healthcare Provider Details

I. General information

NPI: 1992263123
Provider Name (Legal Business Name): MITCHELL RAY BUERCK
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/06/2019
Last Update Date: 08/18/2024
Certification Date: 08/18/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2937 S BRENTWOOD BLVD
BRENTWOOD MO
63144-2713
US

IV. Provider business mailing address

4940 GRANITE DR
SMITHTON IL
62285-3635
US

V. Phone/Fax

Practice location:
  • Phone: 314-961-3804
  • Fax:
Mailing address:
  • Phone: 618-719-4006
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number2024031307
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: