Basic Information
| Provider Information | |||||||||
| NPI: | 1992810857 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KELLA | ||||||||
| FirstName: | TIMOTHY | ||||||||
| MiddleName: | L | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 660 S EUCLID AVE | ||||||||
| Address2: | CB 8072 | ||||||||
| City: | SAINT LOUIS | ||||||||
| State: | MO | ||||||||
| PostalCode: | 631101010 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3149965225 | ||||||||
| FaxNumber: | 3149910943 | ||||||||
| Practice Location | |||||||||
| Address1: | 3015 N BALLAS RD | ||||||||
| Address2: | DEPT EMERGENCY MEDICINE | ||||||||
| City: | SAINT LOUIS | ||||||||
| State: | MO | ||||||||
| PostalCode: | 631312329 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3149665000 | ||||||||
| FaxNumber: | 3147473338 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/20/2006 | ||||||||
| LastUpdateDate: | 12/20/2021 | ||||||||
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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 | 208D00000X | R4D92 | MO | N | Allopathic & Osteopathic Physicians | General Practice | 207P00000X | R4D92 | MO | Y | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 202225504 | 05 | MO | MEDICAID |