Healthcare Provider Details

I. General information

NPI: 1972100535
Provider Name (Legal Business Name): MICHAEL ESARE-BECKSON
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/07/2020
Last Update Date: 10/07/2020
Certification Date: 10/07/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11278 SCHUETZ RD
SAINT LOUIS MO
63146-4957
US

IV. Provider business mailing address

4433 PERSHING AVE APT 302
SAINT LOUIS MO
63108-2512
US

V. Phone/Fax

Practice location:
  • Phone: 314-991-4066
  • Fax:
Mailing address:
  • Phone: 269-697-3891
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number20200333857
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: