Basic Information
| Provider Information | |||||||||
| NPI: | 1457510604 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | RENNER | ||||||||
| FirstName: | MATTHEW | ||||||||
| MiddleName: | EDWARD | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | PT | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | RENNER | ||||||||
| OtherFirstName: | MATT | ||||||||
| OtherMiddleName: | |||||||||
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| OtherCredential: | PT | ||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 6744 CLAYTON RD | ||||||||
| Address2: | SUITE 220 | ||||||||
| City: | SAINT LOUIS | ||||||||
| State: | MO | ||||||||
| PostalCode: | 631171637 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3146441978 | ||||||||
| FaxNumber: | 3146471350 | ||||||||
| Practice Location | |||||||||
| Address1: | 6744 CLAYTON RD | ||||||||
| Address2: | SUITE 220 | ||||||||
| City: | SAINT LOUIS | ||||||||
| State: | MO | ||||||||
| PostalCode: | 631171637 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3146441978 | ||||||||
| FaxNumber: | 3146471350 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/03/2008 | ||||||||
| LastUpdateDate: | 06/03/2008 | ||||||||
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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 | 2007008752 | MO | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 481617 | 01 | MO | HEALTHLINK | OTHER | 120764 | 01 | MO | BCBS-MO | OTHER |