Provider Demographics
NPI:1669478970
Name:KUCIEJCZYK-KERNAN, THOMAS PATRICK (MD)
Entity Type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:PATRICK
Last Name:KUCIEJCZYK-KERNAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:THOMAS
Other - Middle Name:PATRICK
Other - Last Name:KERNAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:1717 BIDDLE ST
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63106-3454
Mailing Address - Country:US
Mailing Address - Phone:314-898-1700
Mailing Address - Fax:314-814-8542
Practice Address - Street 1:3930 S BROADWAY
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63118-4626
Practice Address - Country:US
Practice Address - Phone:314-898-1700
Practice Address - Fax:314-814-8542
Is Sole Proprietor?:No
Enumeration Date:2005-06-22
Last Update Date:2016-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOR6J90207Q00000X, 2084P0015X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No2084P0015XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychosomatic Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO202710109Medicaid
MO202710109Medicaid
20010422Medicare PIN