Healthcare Provider Details

I. General information

NPI: 1255085593
Provider Name (Legal Business Name): MICHAEL ROSS COFFEY PTA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/07/2022
Last Update Date: 02/07/2022
Certification Date: 02/07/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11902 BLUE RIDGE EXT STE 11906-B
GRANDVIEW MO
64030-1100
US

IV. Provider business mailing address

1200 CORPORATE DR STE 400
HOOVER AL
35242-5424
US

V. Phone/Fax

Practice location:
  • Phone: 816-298-6131
  • Fax: 816-298-6423
Mailing address:
  • Phone: 423-238-7217
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number14-03800
License Number StateKS
# 2
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number2022003376
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: