MEDICARE: MARK A DEEMER ATH TR

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	2255A2300X	Athletic Trainer		IL

General Provider Information

NPI Number	:	1437148723
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARK A DEEMER ATH TR

Provider Business Mailing Address
First Line	:	PO BOX 24007
Second Line	:
City	:	BELLEVILLE
State	:	IL
Zip	:	62223-9007
Country	:	US
Telephone Number	:	618-222-9999
Fax Number	:	618-222-9337

Provider Business Practice Location Address
First Line	:	4550 MEMORIAL DR
Second Line	:	SUITE G-100
City	:	BELLEVILLE
State	:	IL
Zip	:	62226-5359
Country	:	US
Telephone Number	:	618-236-2246
Fax Number	:	618-236-2315

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

Provider Enumeration Date	:	10/19/2005
Last Update Date	:	07/08/2007

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