Basic Information
| Provider Information | |||||||||
| NPI: | 1922048420 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | WASHINGTON UNIVERSITY | ||||||||
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| OtherOrganizationName: | WASHINGTON UNIVERSITY, DEPARTMENT OF PHYSICAL THERAPY | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7425 FORSYTH BLVD | ||||||||
| Address2: | CAMPUS BOX 8221 | ||||||||
| City: | SAINT LOUIS | ||||||||
| State: | MO | ||||||||
| PostalCode: | 631052171 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3149350770 | ||||||||
| FaxNumber: | 3149350575 | ||||||||
| Practice Location | |||||||||
| Address1: | 660 S EUCLID AVE | ||||||||
| Address2: | |||||||||
| City: | SAINT LOUIS | ||||||||
| State: | MO | ||||||||
| PostalCode: | 631101010 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3142861579 | ||||||||
| FaxNumber: | 3142861473 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/07/2006 | ||||||||
| LastUpdateDate: | 10/30/2020 | ||||||||
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| AuthorizedOfficialLastName: | EGHIGIAN | ||||||||
| AuthorizedOfficialFirstName: | CATHY | ||||||||
| AuthorizedOfficialMiddleName: | L | ||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR, CREDENTIALING OPERATIONS | ||||||||
| AuthorizedOfficialTelephone: | 3142730770 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MS. | ||||||||
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| NPICertificationDate: | 10/30/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | N | 193200000X MULTI-SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | 225X00000X | N | 193200000X MULTI-SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist | 235Z00000X | N | 193200000X MULTI-SPECIALTY GROUP | Speech, Language and Hearing Service Providers | Speech-Language Pathologist | 261QM1300X | N | Ambulatory Health Care Facilities | Clinic/Center | Multi-Specialty | 261QP2000X | Y | Ambulatory Health Care Facilities | Clinic/Center | Physical Therapy |
ID Information
| ID | Type | State | Issuer | Description | 64-00252 | 01 | MO | UHC GROUP NUMBER | OTHER | 43843 | 01 | MO | GHP MASTER VENDOR | OTHER | 610916400 | 01 | MO | DEPARTMENT OF LABOR | OTHER | 673341 | 01 | MO | AETNA HMO GROUP | OTHER |