Basic Information
| Provider Information | |||||||||
| NPI: | 1336180249 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DOHERTY | ||||||||
| FirstName: | KEVIN | ||||||||
| MiddleName: | PATRICK | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | PT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 13537 BARRETT PARKWAY DRIVE | ||||||||
| Address2: | SUITE 105 | ||||||||
| City: | BALLWIN | ||||||||
| State: | MO | ||||||||
| PostalCode: | 630215866 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3148219126 | ||||||||
| FaxNumber: | 3148219142 | ||||||||
| Practice Location | |||||||||
| Address1: | 14825 N OUTER FORTY ROAD | ||||||||
| Address2: | SUITE 300 | ||||||||
| City: | CHESTERFIELD | ||||||||
| State: | MO | ||||||||
| PostalCode: | 630050002 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6368121211 | ||||||||
| FaxNumber: | 6368120159 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/10/2006 | ||||||||
| LastUpdateDate: | 05/11/2010 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2251X0800X | 2006009447 | MO | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | Orthopedic |
No ID Information.