1902197767 NPI number — INTERNAL MEDICINE OF KIRKWOOD, LLC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1902197767 NPI number — INTERNAL MEDICINE OF KIRKWOOD, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
INTERNAL MEDICINE OF KIRKWOOD, LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1902197767
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/26/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
232 S WOODS MILL RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CHESTERFIELD
Provider Business Mailing Address State Name:
MO
Provider Business Mailing Address Postal Code:
63017-3406
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
636-685-7804
Provider Business Mailing Address Fax Number:
314-576-2434

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
461 S KIRKWOOD RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SAINT LOUIS
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
63122-6119
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
314-965-1513
Provider Business Practice Location Address Fax Number:
314-965-1063
Provider Enumeration Date:
04/28/2011

Additional Information

Authorized Official

Authorized Official Last Name:
SNIDER
Authorized Official First Name:
JAMES
Authorized Official Middle Name:
Authorized Official Title or Position:
VP PHYSICIAN NETWORK
Authorized Official Telephone Number:
636-685-7804

Provider Taxonomy Codes

  • Taxonomy code: 207R00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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