Healthcare Provider Details

I. General information

NPI: 1922020247
Provider Name (Legal Business Name): GREG P WILLIAMS ATC, CSCS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/24/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

675 OLD BALLAS RD SUITE 210
SAINT LOUIS MO
63141-7083
US

IV. Provider business mailing address

675 OLD BALLAS RD SUITE 210
SAINT LOUIS MO
63141-7083
US

V. Phone/Fax

Practice location:
  • Phone: 314-994-7468
  • Fax: 314-994-0796
Mailing address:
  • Phone: 314-994-7468
  • Fax: 314-994-0796

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number118076
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: