Provider Demographics
NPI:1104014489
Name:KIM LEE MCDONALD, M.D., P.C.
Entity Type:Organization
Organization Name:KIM LEE MCDONALD, M.D., P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:KIM
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:MCDONALD
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:314-838-8839
Mailing Address - Street 1:4585 WASHINGTON ST
Mailing Address - Street 2:SUITE C4
Mailing Address - City:FLORISSANT
Mailing Address - State:MO
Mailing Address - Zip Code:63033-5858
Mailing Address - Country:US
Mailing Address - Phone:314-838-8839
Mailing Address - Fax:314-838-4291
Practice Address - Street 1:4585 WASHINGTON ST
Practice Address - Street 2:SUITE C4
Practice Address - City:FLORISSANT
Practice Address - State:MO
Practice Address - Zip Code:63033-5858
Practice Address - Country:US
Practice Address - Phone:314-838-8839
Practice Address - Fax:314-838-4291
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-11
Last Update Date:2008-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOR4E37207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO1386636009OtherINDIVIDUAL NPI #
MOA12821Medicare UPIN