MEDICARE: GERIATRIC PRACTITIONER SERVICES, LLC

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	314000000X	Skilled Nursing Facility	118164	MO

General Provider Information

NPI Number	:	1861878092
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GERIATRIC PRACTITIONER SERVICES, LLC

Provider Business Mailing Address
First Line	:	11361 BRIERHALL CIR
Second Line	:
City	:	MARYLAND HEIGHTS
State	:	MO
Zip	:	63043-5002
Country	:	US
Telephone Number	:	314-753-6714
Fax Number	:

Provider Business Practice Location Address
First Line	:	11361 BRIERHALL CIR
Second Line	:
City	:	MARYLAND HEIGHTS
State	:	MO
Zip	:	63043-5002
Country	:	US
Telephone Number	:	314-753-6714
Fax Number	:

Authorized Official
Title or Position	:	SOLE MEMBER
Name	:	DR. CATHERINE ANN KUSH
Credential	:	DNP, GNP-BC
Telephone Number	:	314-753-6714

Provider Enumeration Date	:	08/11/2015
Last Update Date	:	08/11/2015

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