Provider Demographics
NPI:1508841875
Name:KENNETH G SELKE MD
Entity Type:Organization
Organization Name:KENNETH G SELKE MD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:G
Authorized Official - Last Name:SELKE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:314-469-2182
Mailing Address - Street 1:224 S WOODS MILL RD
Mailing Address - Street 2:STE. 670 SOUTH
Mailing Address - City:CHESTERFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:63017-3451
Mailing Address - Country:US
Mailing Address - Phone:314-469-2182
Mailing Address - Fax:314-469-5725
Practice Address - Street 1:224 S WOODS MILL RD
Practice Address - Street 2:STE. 670 SOUTH
Practice Address - City:CHESTERFIELD
Practice Address - State:MO
Practice Address - Zip Code:63017-3451
Practice Address - Country:US
Practice Address - Phone:314-469-2182
Practice Address - Fax:314-469-5725
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-12-09
Last Update Date:2013-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
C4134OtherRAILROAD MEDICARE
110037903OtherRAILROAD MEDICARE
C4134OtherRAILROAD MEDICARE
MO000013240Medicare ID - Type Unspecified
110037903Medicare PIN
CK4134Medicare PIN