Provider Demographics
NPI:1023195351
Name:KEVIN L. THRELKELD, M.D., LLC
Entity Type:Organization
Organization Name:KEVIN L. THRELKELD, M.D., LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN REGISTERED AGENT
Authorized Official - Prefix:
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:L
Authorized Official - Last Name:THRELKELD
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:636-390-1854
Mailing Address - Street 1:PO BOX 270003
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63127-0003
Mailing Address - Country:US
Mailing Address - Phone:636-390-1854
Mailing Address - Fax:
Practice Address - Street 1:204 N MAIN ST
Practice Address - Street 2:
Practice Address - City:O FALLON
Practice Address - State:MO
Practice Address - Zip Code:63366-2203
Practice Address - Country:US
Practice Address - Phone:636-240-3420
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-01
Last Update Date:2019-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOMDR5P58207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOF07100Medicare UPIN