MEDICARE: BREFELD PHYSICAL THERAPY SERVICES PC

Medicare Provider Information

Scope of Practice

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

#	Taxonomy Code	Taxonomy	License Number State
1	235Z00000X	Speech-Language Pathologist	IL
2	225X00000X	Occupational Therapist	IL
3	225100000X	Physical Therapist	IL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	5330619	OTHER		AETNA
2	0001415008	OTHER	IL	BCBS OF IL

General Provider Information

NPI Number	:	1053308015
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BREFELD PHYSICAL THERAPY SERVICES PC

Provider Business Mailing Address
First Line	:	106 LINCOLN PLACE CT
Second Line	:
City	:	BELLEVILLE
State	:	IL
Zip	:	62221-5884
Country	:	US
Telephone Number	:	618-236-7588
Fax Number	:	618-236-7589

Provider Business Practice Location Address
First Line	:	106 LINCOLN PLACE CT
Second Line	:
City	:	BELLEVILLE
State	:	IL
Zip	:	62221-5884
Country	:	US
Telephone Number	:	618-236-7588
Fax Number	:	618-236-7589

Authorized Official
Title or Position	:	PRESIDENT
Name	:	JOAN L BREFELD
Credential	:	PT PCS
Telephone Number	:	618-236-7588

Provider Enumeration Date	:	10/04/2005
Last Update Date	:	11/21/2007

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