MEDICARE: DR. EDGAR EVERETT III D.C.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	111N00000X	Chiropractor	2006022760	MO

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	200250	OTHER	MO	BCBS

General Provider Information

NPI Number	:	1033177746
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. EDGAR EVERETT III D.C.

Provider Business Mailing Address
First Line	:	2050 WOODSON RD
Second Line	:	STE #101
City	:	OVERLAND
State	:	MO
Zip	:	63114-5644
Country	:	US
Telephone Number	:	314-713-1656
Fax Number	:	314-395-0607

Provider Business Practice Location Address
First Line	:	2050 WOODSON RD
Second Line	:	STE #101
City	:	OVERLAND
State	:	MO
Zip	:	63114-5644
Country	:	US
Telephone Number	:	314-713-1656
Fax Number	:	314-395-0607

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/02/2006
Last Update Date	:	09/09/2008

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