MEDICARE: MICHAEL GONZALES 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	2005005735	MO

General Provider Information

NPI Number	:	1215269675
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MICHAEL GONZALES PT

Provider Business Mailing Address
First Line	:	2415 N KINGSHIGHWAY BLVD
Second Line	:
City	:	SAINT LOUIS
State	:	MO
Zip	:	63113-1109
Country	:	US
Telephone Number	:	314-361-1300
Fax Number	:	314-367-4841

Provider Business Practice Location Address
First Line	:	2415 N KINGSHIGHWAY BLVD
Second Line	:
City	:	SAINT LOUIS
State	:	MO
Zip	:	63113-1109
Country	:	US
Telephone Number	:	314-361-1300
Fax Number	:	314-367-4841

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

Provider Enumeration Date	:	02/09/2010
Last Update Date	:	02/09/2010

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