Healthcare Provider Details

I. General information

NPI: 1174031728
Provider Name (Legal Business Name): DURKIN PHYSICAL MEDICINE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/17/2018
Last Update Date: 01/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1099 MILWAUKEE ST STE 240
KIRKWOOD MO
63122-7360
US

IV. Provider business mailing address

4340 MARYLAND AVE APT 9C
SAINT LOUIS MO
63108-2700
US

V. Phone/Fax

Practice location:
  • Phone: 314-822-1502
  • Fax:
Mailing address:
  • Phone: 773-573-0895
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111NR0400X
TaxonomyRehabilitation Chiropractor
License Number2018000924
License Number StateMO

VIII. Authorized Official

Name: DR. DANIEL PATRICK DURKIN
Title or Position: CLINICIAN
Credential: DC
Phone: 773-573-0895