MEDICARE: MRS. TRACY L PULLEY ATC

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	2081S0010X	Sports Medicine (Physical Medicine & Rehabilitation) Physician	2003026732	MO

General Provider Information

NPI Number	:	1124237490
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. TRACY L PULLEY ATC

Provider Business Mailing Address
First Line	:	644 S PAM AVE
Second Line	:
City	:	SAINT CHARLES
State	:	MO
Zip	:	63301-4857
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	13537 BARRETT PARKWAY DR
Second Line	:	SUITE 105
City	:	BALLWIN
State	:	MO
Zip	:	63021-5899
Country	:	US
Telephone Number	:	314-821-9126
Fax Number	:

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

Provider Enumeration Date	:	05/22/2007
Last Update Date	:	07/08/2007

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