Provider Demographics
NPI:1992263123
Name:BUERCK, MITCHELL RAY
Entity type:Individual
Prefix:
First Name:MITCHELL
Middle Name:RAY
Last Name:BUERCK
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4940 GRANITE DR
Mailing Address - Street 2:
Mailing Address - City:SMITHTON
Mailing Address - State:IL
Mailing Address - Zip Code:62285-3635
Mailing Address - Country:US
Mailing Address - Phone:618-719-4006
Mailing Address - Fax:
Practice Address - Street 1:2937 S BRENTWOOD BLVD
Practice Address - Street 2:
Practice Address - City:BRENTWOOD
Practice Address - State:MO
Practice Address - Zip Code:63144-2713
Practice Address - Country:US
Practice Address - Phone:314-961-3804
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-03-06
Last Update Date:2024-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
2255A2300X
MO2024031307225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO815976827OtherUNITED HEALTHCARE