Basic Information
| Provider Information | |||||||||
| NPI: | 1679514095 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | KENNETH GERDES , LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1209 | ||||||||
| Address2: | |||||||||
| City: | MARYLAND HEIGHTS | ||||||||
| State: | MO | ||||||||
| PostalCode: | 630430209 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3144322580 | ||||||||
| FaxNumber: | 3149918960 | ||||||||
| Practice Location | |||||||||
| Address1: | 11155 DUNN RD | ||||||||
| Address2: | SUITE 211N | ||||||||
| City: | SAINT LOUIS | ||||||||
| State: | MO | ||||||||
| PostalCode: | 631366150 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3144322580 | ||||||||
| FaxNumber: | 3149918960 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/09/2006 | ||||||||
| LastUpdateDate: | 04/06/2016 | ||||||||
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| AuthorizedOfficialLastName: | JORDAN | ||||||||
| AuthorizedOfficialFirstName: | JACKI | ||||||||
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| AuthorizedOfficialTitleorPosition: | BILLING MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 3144322580 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | 117124 | MO | Y | 193400000X SINGLE SPECIALTY GROUP | Other Service Providers | Specialist |
ID Information
| ID | Type | State | Issuer | Description | 500745609 | 05 | MO | MEDICAID | DE2084 | 01 | MO | RR MCR GROUP PROV# | OTHER |