Healthcare Provider Details

I. General information

NPI: 1033484795
Provider Name (Legal Business Name): PHYSICAL MEDICINE GROUP, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/14/2012
Last Update Date: 06/05/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8633 MEXICO RD
O FALLON MO
63366-7506
US

IV. Provider business mailing address

8633 MEXICO RD
O FALLON MO
63366-7506
US

V. Phone/Fax

Practice location:
  • Phone: 636-272-8888
  • Fax: 636-272-7385
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RC0200X
TaxonomyCritical Care Medicine (Internal Medicine) Physician
License Number2006038287
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number2006038287
License Number StateMO

VIII. Authorized Official

Name: MICHAEL WILLIAMS
Title or Position: PRESIDENT
Credential:
Phone: 63627288888