=====================================================
General NPI Number Information
=====================================================
NPI Number | 1780647842
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | DREW MILLER DINTELMANN ATC, CSCS
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/10/2006
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1 MEMORIAL DR
-----------------------------------------------------
City | ALTON
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 62002-6722
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 618-288-3078
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 7801 MEADOWLARK DR
-----------------------------------------------------
City | GODFREY
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 62035-2363
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 618-467-1552
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2255A2300X
-----------------------------------------------------
Taxonomy Name | Athletic Trainer
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------