MEDICARE: MRS. DONNA MARIE FREDERICK P.T.

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	104699	MO

General Provider Information

NPI Number	:	1821232257
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. DONNA MARIE FREDERICK P.T.

Provider Business Mailing Address
First Line	:	3310 CORDES DR
Second Line	:
City	:	SAINT LOUIS
State	:	MO
Zip	:	63125-4430
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	3310 CORDES DR
Second Line	:
City	:	SAINT LOUIS
State	:	MO
Zip	:	63125-4430
Country	:	US
Telephone Number	:	314-894-3547
Fax Number	:

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

Provider Enumeration Date	:	04/29/2009
Last Update Date	:	04/29/2009

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