Basic Information
| Provider Information | |||||||||
| NPI: | 1720020100 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GERDES | ||||||||
| FirstName: | KENNETH | ||||||||
| MiddleName: | L | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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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: | 06/12/2006 | ||||||||
| LastUpdateDate: | 04/06/2016 | ||||||||
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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 | 207RN0300X | R6G82 | MO | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Nephrology | 207RN0300X | 036-082405 | IL | N | Allopathic & Osteopathic Physicians | Internal Medicine | Nephrology |
ID Information
| ID | Type | State | Issuer | Description | 23548 | 01 | MO | BCBS PROV# | OTHER | 202382115 | 05 | MO | MEDICAID | P00278412 | 01 | MO | RR MCR PROV# | OTHER | 733423 | 01 | MO | HEALTHLINK PROV# | OTHER | 202034729 | 01 | MO | TRICARE WEST PROV# | OTHER | 237776 | 01 | MO | GHP/CMR PROV# | OTHER |