MEDICARE: ALLSTAR PHYSICAL THERAPY, 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	225100000X	Physical Therapist

General Provider Information

NPI Number	:	1932486073
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ALLSTAR PHYSICAL THERAPY, LLC

Provider Business Mailing Address
First Line	:	221 W POINTE DR
Second Line	:	SUITE 1
City	:	SWANSEA
State	:	IL
Zip	:	62226-8306
Country	:	US
Telephone Number	:	618-416-6500
Fax Number	:	618-416-6503

Provider Business Practice Location Address
First Line	:	1933 SCHUETZ RD
Second Line	:
City	:	SAINT LOUIS
State	:	MO
Zip	:	63146-3550
Country	:	US
Telephone Number	:	618-416-6500
Fax Number	:	618-416-6503

Authorized Official
Title or Position	:	MEMBER MANAGER
Name	:	TIMOTHY SCOTT ZICKUS
Credential	:	MPT
Telephone Number	:	314-603-8299

Provider Enumeration Date	:	11/03/2011
Last Update Date	:	11/03/2011

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