Provider Demographics
NPI:1013305804
Name:W DAVID KISTLER JR MD LLC
Entity Type:Organization
Organization Name:W DAVID KISTLER JR MD LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:MARILYN
Authorized Official - Middle Name:H
Authorized Official - Last Name:KISTLER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:314-721-0411
Mailing Address - Street 1:950 FRANCIS PL
Mailing Address - Street 2:STE 113
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63105-2465
Mailing Address - Country:US
Mailing Address - Phone:314-721-0411
Mailing Address - Fax:314-721-5968
Practice Address - Street 1:950 FRANCIS PL
Practice Address - Street 2:STE 113
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63105-2465
Practice Address - Country:US
Practice Address - Phone:314-721-0411
Practice Address - Fax:314-721-5968
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-12-31
Last Update Date:2015-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO817008OtherCOVENTRY
MO178790OtherANTHEM BLUE CROSS BLUE SHIELD
MOP00174135OtherRAILROAD MEDICARE
MO200690907Medicaid
MO200690907Medicaid