Basic Information
| Provider Information | |||||||||
| NPI: | 1295703445 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | THRELKELD | ||||||||
| FirstName: | KEVIN | ||||||||
| MiddleName: | L. | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 121 SAINT LUKES CENTER DR STE 402 | ||||||||
| Address2: | |||||||||
| City: | CHESTERFIELD | ||||||||
| State: | MO | ||||||||
| PostalCode: | 630173519 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3142056160 | ||||||||
| FaxNumber: | 3145905918 | ||||||||
| Practice Location | |||||||||
| Address1: | 121 SAINT LUKES CENTER DR STE 402 | ||||||||
| Address2: | |||||||||
| City: | CHESTERFIELD | ||||||||
| State: | MO | ||||||||
| PostalCode: | 630173519 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3142056160 | ||||||||
| FaxNumber: | 3145905918 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/12/2006 | ||||||||
| LastUpdateDate: | 12/04/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 12/04/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | R5P58 | MO | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207R00000X | MDR5P58 | MO | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 207969510 | 05 | MO | MEDICAID |