MEDICARE: BONNIE JOYCE BURKE PT, MTC

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	225100000X	Physical Therapist	070002879	IL

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	P00150036	OTHER	IL	RR MEDICARE

General Provider Information

NPI Number	:	1043244478
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BONNIE JOYCE BURKE PT, MTC

Provider Business Mailing Address
First Line	:	605 OLD BALLAS RD STE 128
Second Line	:
City	:	SAINT LOUIS
State	:	MO
Zip	:	63141-7070
Country	:	US
Telephone Number	:	314-801-8776
Fax Number	:	314-801-8775

Provider Business Practice Location Address
First Line	:	605 OLD BALLAS RD STE 128
Second Line	:
City	:	SAINT LOUIS
State	:	MO
Zip	:	63141-7070
Country	:	US
Telephone Number	:	314-801-8776
Fax Number	:	314-801-8775

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

Provider Enumeration Date	:	07/10/2006
Last Update Date	:	02/23/2022

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