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NPI Code Detail

MEDICARE: DREW MILLER DINTELMANN ATC, CSCS

MEDICARE: DREW MILLER DINTELMANN ATC, CSCS
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
12255A2300XAthletic TrainerIL

General Provider Information

NPI Number : 1780647842
Entity Type Code : Individual
Provider Name (Legal Business Name) : DREW MILLER DINTELMANN ATC, CSCS
Provider Business Mailing Address
First Line : 7801 MEADOWLARK DR
Second Line :
City : GODFREY
State : IL
Zip : 62035-2363
Country : US
Telephone Number : 618-467-1552
Fax Number :
Provider Business Practice Location Address
First Line : 1 MEMORIAL DR
Second Line :
City : ALTON
State : IL
Zip : 62002-6722
Country : US
Telephone Number : 618-288-3078
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 04/10/2006
Last Update Date : 07/08/2007

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