Basic Information
| Provider Information | |||||||||
| NPI: | 1558962076 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BURKS | ||||||||
| FirstName: | TEVIN | ||||||||
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| Credential: | PT,DPT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 809 FOXGROVE DR | ||||||||
| Address2: | |||||||||
| City: | FAIRVIEW HEIGHTS | ||||||||
| State: | IL | ||||||||
| PostalCode: | 622082095 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9019075384 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1021 W E ST | ||||||||
| Address2: | |||||||||
| City: | BELLEVILLE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 622201055 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6182332095 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/02/2020 | ||||||||
| LastUpdateDate: | 11/02/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 11/01/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2251G0304X | 070024075 | IL | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | Geriatrics |
No ID Information.