Healthcare Provider Details

I. General information

NPI: 1588871248
Provider Name (Legal Business Name): RUSSELL HUGH EAVES PT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/16/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

224 S WOODS MILL RD SUITE 610 SOUTH
CHESTERFIELD MO
63017
US

IV. Provider business mailing address

5680 OAK GROVE CHURCH RD
LONEDELL MO
63066
US

V. Phone/Fax

Practice location:
  • Phone: 314-205-6551
  • Fax: 314-576-2371
Mailing address:
  • Phone: 636-629-5911
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number00983
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: