MEDICARE: BRENTWOOD PHYSICAL THERAPY LIMITED

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	261QP2000X	Physical Therapy Clinic/Center

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	31348	OTHER	MO	BCBS

General Provider Information

NPI Number	:	1336122266
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BRENTWOOD PHYSICAL THERAPY LIMITED

Provider Business Mailing Address
First Line	:	2558 S BRENTWOOD BLVD
Second Line	:
City	:	SAINT LOUIS
State	:	MO
Zip	:	63144-2309
Country	:	US
Telephone Number	:	314-961-8940
Fax Number	:	314-961-8969

Provider Business Practice Location Address
First Line	:	2558 S BRENTWOOD BLVD
Second Line	:
City	:	SAINT LOUIS
State	:	MO
Zip	:	63144-2309
Country	:	US
Telephone Number	:	314-961-8940
Fax Number	:	314-961-8969

Authorized Official
Title or Position	:	PRESIDENT
Name	:	MR. ROBERT SHAWN TUCKER
Credential	:	PT
Telephone Number	:	314-961-8940

Provider Enumeration Date	:	11/23/2005
Last Update Date	:	02/03/2013

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