MEDICARE: MR. JAY ERIC DIAMOND PT

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	01635	MO

General Provider Information

NPI Number	:	1043315930
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. JAY ERIC DIAMOND PT

Provider Business Mailing Address
First Line	:	600 OAKMONT LN
Second Line	:	STE 600C
City	:	WESTMONT
State	:	IL
Zip	:	60559-5548
Country	:	US
Telephone Number	:	630-575-6250
Fax Number	:	630-575-7450

Provider Business Practice Location Address
First Line	:	3734 S KINGSHIGHWAY BLVD
Second Line	:
City	:	SAINT LOUIS
State	:	MO
Zip	:	63109-1800
Country	:	US
Telephone Number	:	314-351-7172
Fax Number	:	314-351-6885

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

Provider Enumeration Date	:	09/14/2006
Last Update Date	:	07/01/2020

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