Provider Demographics
NPI:1578500039
Name:PERRY, KIMBERLY G (DO)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:G
Last Name:PERRY
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1836 LACKLAND HILL PKWY
Mailing Address - Street 2:ATTN: CREDENTIALING
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63146-3572
Mailing Address - Country:US
Mailing Address - Phone:314-989-0300
Mailing Address - Fax:314-810-1399
Practice Address - Street 1:300 1ST CAPITOL DR
Practice Address - Street 2:
Practice Address - City:SAINT CHARLES
Practice Address - State:MO
Practice Address - Zip Code:63301-2844
Practice Address - Country:US
Practice Address - Phone:636-947-5000
Practice Address - Fax:636-947-5090
Is Sole Proprietor?:No
Enumeration Date:2006-06-01
Last Update Date:2010-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO101732207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO1578500039Medicaid
IL$$$$$$$$$Medicaid
MO1578500039Medicaid
MO196050091Medicare ID - Type UnspecifiedSJH-MO
MO1578500039Medicaid
IL$$$$$$$$$-5Medicaid
MO156580031Medicare PIN