Provider Demographics
NPI:1720020100
Name:GERDES, KENNETH L (MD)
Entity Type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:L
Last Name:GERDES
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1209
Mailing Address - Street 2:
Mailing Address - City:MARYLAND HEIGHTS
Mailing Address - State:MO
Mailing Address - Zip Code:63043-0209
Mailing Address - Country:US
Mailing Address - Phone:314-432-2580
Mailing Address - Fax:314-991-8960
Practice Address - Street 1:11155 DUNN RD
Practice Address - Street 2:SUITE 211N
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63136-6150
Practice Address - Country:US
Practice Address - Phone:314-432-2580
Practice Address - Fax:314-991-8960
Is Sole Proprietor?:No
Enumeration Date:2006-06-12
Last Update Date:2016-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOR6G82207RN0300X
IL036-082405207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO23548OtherBCBS PROV#
MO202382115Medicaid
MOP00278412OtherRR MCR PROV#
MO733423OtherHEALTHLINK PROV#
MO202034729OtherTRICARE WEST PROV#
MO237776OtherGHP/CMR PROV#
MOP00278412OtherRR MCR PROV#