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General NPI Number Information
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NPI Number | 1164829149
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Entity Type | Organization
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Legal Business Name | ELECTRODIAGNOSTIC & REHAB MEDICINE
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Dates
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Enumeration Date | 11/19/2014
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Last Update Date | 11/19/2014
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Provider Practice Location Address
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Address Line | 3107 FREDERICK AVE SUITE C
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City | SAINT JOSEPH
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State | MO
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Zip | 64506-2956
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Country | US
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Telephone | 816-233-9888
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Fax | 816-233-0414
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Provider Business Mailing Address
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Address Line | 3107 FREDERICK AVE SUITE C
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City | SAINT JOSEPH
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State | MO
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Zip | 64506-2956
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Country | US
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Telephone | 816-233-9888
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Fax | 816-233-0414
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Authorized Official
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Title or Position | PRESIDENT/SECRETARY
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Name | AMY L BELVILLE
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Credential | D.O.
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Telephone | 816-233-9888
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 204R00000X
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Taxonomy Name | Electrodiagnostic Medicine Physician
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License Number | 2003013938
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License Number State | MO
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