Provider Demographics
NPI:1619593258
Name:MCDERMOTT, KELLY EILEEN (MD)
Entity Type:Individual
Prefix:DR
First Name:KELLY
Middle Name:EILEEN
Last Name:MCDERMOTT
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 60352
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63160-0352
Mailing Address - Country:US
Mailing Address - Phone:314-747-3969
Mailing Address - Fax:314-996-3230
Practice Address - Street 1:4921 PARKVIEW PL
Practice Address - Street 2:DIV IM GENERAL MED, STE 12B
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63110-1032
Practice Address - Country:US
Practice Address - Phone:314-747-3969
Practice Address - Fax:314-996-3230
Is Sole Proprietor?:No
Enumeration Date:2020-06-19
Last Update Date:2024-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2023001041207R00000X, 208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO200085095Medicaid