Healthcare Provider Details

I. General information

NPI: 1821001918
Provider Name (Legal Business Name): PROFESSIONAL CARE PROVIDERS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/13/2006
Last Update Date: 04/29/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

723 1ST CAPITOL DR
SAINT CHARLES MO
63301-2729
US

IV. Provider business mailing address

2025 ZUMBEHL RD #45
SAINT CHARLES MO
63303-2723
US

V. Phone/Fax

Practice location:
  • Phone: 636-577-1357
  • Fax:
Mailing address:
  • Phone: 636-577-1357
  • Fax: 636-447-1202

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number104933
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number33327
License Number StateMO

VIII. Authorized Official

Name: RAY BARTLETT
Title or Position: PRESIDENT
Credential: P.A.
Phone: 636-577-1357