=====================================================
General NPI Number Information
=====================================================
NPI Number | 1114143229
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | LISA MARIE BUERGLER MPT
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/17/2007
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 11701 BORMAN DR STE 280
-----------------------------------------------------
City | SAINT LOUIS
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 63146-4199
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 866-433-9555
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 8 THE BOULEVARD APT. 307
-----------------------------------------------------
City | RICHMOND HEIGHTS
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 63117
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 314-565-1821
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 174400000X
-----------------------------------------------------
Taxonomy Name | Specialist
-----------------------------------------------------
License Number | 2006011311
-----------------------------------------------------
License Number State | MO
-----------------------------------------------------