Healthcare Provider Details

I. General information

NPI: 1700931946
Provider Name (Legal Business Name): BRYAN H DONNELLY PT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/25/2007
Last Update Date: 08/06/2007
Certification Date:
Deactivation Date: 07/17/2007
Reactivation Date: 08/06/2007

III. Provider practice location address

608 OLD ROUTE 66 ST JOHNS THERAPY SERVICES
ST ROBERT MO
65584
US

IV. Provider business mailing address

PO BOX 650 608 OLD ROUTE 66 ST JOHNS THERAPY SERVICES
ST ROBERT MO
65584
US

V. Phone/Fax

Practice location:
  • Phone: 573-336-8991
  • Fax: 573-336-8993
Mailing address:
  • Phone: 573-336-8991
  • Fax: 573-336-8993

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number00347
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: