Provider Demographics
NPI:1376835207
Name:PROFESSIONAL INTERNAL MEDICINE LLC
Entity Type:Organization
Organization Name:PROFESSIONAL INTERNAL MEDICINE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:J
Authorized Official - Last Name:RYBICKI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:314-367-4800
Mailing Address - Street 1:4625 LINDELL BLVD
Mailing Address - Street 2:SUITE 507
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63108-3725
Mailing Address - Country:US
Mailing Address - Phone:314-367-4800
Mailing Address - Fax:314-367-6400
Practice Address - Street 1:4625 LINDELL BLVD
Practice Address - Street 2:SUITE 507
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63108-3725
Practice Address - Country:US
Practice Address - Phone:314-367-4800
Practice Address - Fax:314-367-6400
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-05-11
Last Update Date:2011-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO36902207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty