MEDICARE: ROGER LEE BURTRAW III 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	9863	MN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1588062988
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ROGER LEE BURTRAW III PT

Provider Business Mailing Address
First Line	:	4570 CHURCHILL ST STE 300
Second Line	:
City	:	SHOREVIEW
State	:	MN
Zip	:	55126-2274
Country	:	US
Telephone Number	:	651-481-1071
Fax Number	:	651-481-0042

Provider Business Practice Location Address
First Line	:	4570 CHURCHILL ST STE 300
Second Line	:
City	:	SHOREVIEW
State	:	MN
Zip	:	55126-2274
Country	:	US
Telephone Number	:	651-481-1071
Fax Number	:	651-481-0042

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

Provider Enumeration Date	:	12/17/2014
Last Update Date	:	02/12/2018

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