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General NPI Number Information
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NPI Number | 1992263123
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Entity Type | Individual
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Provider Name | MITCHELL RAY BUERCK
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Gender | Male
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Dates
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Enumeration Date | 03/06/2019
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Last Update Date | 08/18/2024
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Provider Practice Location Address
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Address Line | 2937 S BRENTWOOD BLVD
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City | BRENTWOOD
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State | MO
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Zip | 63144-2713
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Country | US
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Telephone | 314-961-3804
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Fax |
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Provider Business Mailing Address
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Address Line | 4940 GRANITE DR
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City | SMITHTON
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State | IL
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Zip | 62285-3635
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Country | US
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Telephone | 618-719-4006
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2255A2300X
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Taxonomy Name | Athletic Trainer
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 225100000X
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Taxonomy Name | Physical Therapist
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License Number | 2024031307
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License Number State | MO
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