Provider Demographics
NPI:1629185103
Name:BOATRIGHT, KEVIN
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:
Last Name:BOATRIGHT
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:670 MASON RIDGE CENTER DR
Mailing Address - Street 2:SUITE 300
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63141-8573
Mailing Address - Country:US
Mailing Address - Phone:573-756-1744
Mailing Address - Fax:573-756-2499
Practice Address - Street 1:301 N WASHINGTON ST
Practice Address - Street 2:SUITE 5
Practice Address - City:FARMINGTON
Practice Address - State:MO
Practice Address - Zip Code:63640-1751
Practice Address - Country:US
Practice Address - Phone:573-756-1744
Practice Address - Fax:573-756-2499
Is Sole Proprietor?:No
Enumeration Date:2006-08-23
Last Update Date:2012-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOR7D62207Q00000X, 207K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207K00000XAllopathic & Osteopathic PhysiciansAllergy & Immunology
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO201971702Medicaid
MO006012642Medicare ID - Type Unspecified
MO201971702Medicaid