Basic Information
| Provider Information | |||||||||
| NPI: | 1457460107 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ROSHELL | ||||||||
| FirstName: | MARK | ||||||||
| MiddleName: | W | ||||||||
| NamePrefix: | |||||||||
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| Credential: | MS PT | ||||||||
| OtherOrganizationName: | |||||||||
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| OtherLastName: | ROSHELL | ||||||||
| OtherFirstName: | WILLIAM | ||||||||
| OtherMiddleName: | |||||||||
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| OtherCredential: | MIDDLE NAME | ||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 600 OAKMONT LN STE 600C | ||||||||
| Address2: | |||||||||
| City: | WESTMONT | ||||||||
| State: | IL | ||||||||
| PostalCode: | 605595548 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6305756200 | ||||||||
| FaxNumber: | 6309285080 | ||||||||
| Practice Location | |||||||||
| Address1: | 784 GRAVOIS BLUFFS BLVD | ||||||||
| Address2: | |||||||||
| City: | FENTON | ||||||||
| State: | MO | ||||||||
| PostalCode: | 630267726 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6363498060 | ||||||||
| FaxNumber: | 6363499171 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/29/2006 | ||||||||
| LastUpdateDate: | 06/03/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 102416 | MO | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.