Provider Demographics
NPI:1710955752
Name:REICHERT, KIM MICHAEL (DPM)
Entity Type:Individual
Prefix:
First Name:KIM
Middle Name:MICHAEL
Last Name:REICHERT
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2900 FRANK SCOTT PKWY W
Mailing Address - Street 2:SUITE 900
Mailing Address - City:BELLEVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62223-5000
Mailing Address - Country:US
Mailing Address - Phone:618-277-5700
Mailing Address - Fax:618-257-7049
Practice Address - Street 1:2900 FRANK SCOTT PKWY W
Practice Address - Street 2:SUITE 900
Practice Address - City:BELLEVILLE
Practice Address - State:IL
Practice Address - Zip Code:62223-5000
Practice Address - Country:US
Practice Address - Phone:618-277-5700
Practice Address - Fax:618-257-7049
Is Sole Proprietor?:No
Enumeration Date:2006-03-08
Last Update Date:2012-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL016-003257213ES0103X
IL016003257213ES0131X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0131XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot Surgery
No213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
STL2750010OtherUHC
IL102179OtherHEALTHLINK
IL4134729OtherAETNA
IL601-15944OtherBC/BS
IL480026528OtherRAILROAD MEDICARE PTAN
IL102179OtherHEALTHLINK
ILT37882Medicare UPIN