Provider Demographics
NPI:1245475482
Name:DR RAFI KEVORKIAN LLC
Entity type:Organization
Organization Name:DR RAFI KEVORKIAN LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:RAFI
Authorized Official - Middle Name:T
Authorized Official - Last Name:KEVORKIAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:636-634-5865
Mailing Address - Street 1:3760 S LINDBERGH BLVD
Mailing Address - Street 2:SUITE 101
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63127-1358
Mailing Address - Country:US
Mailing Address - Phone:636-634-5865
Mailing Address - Fax:314-849-5716
Practice Address - Street 1:3760 S LINDBERGH BLVD
Practice Address - Street 2:SUITE 101
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63127-1358
Practice Address - Country:US
Practice Address - Phone:636-634-5865
Practice Address - Fax:314-849-5716
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-12-02
Last Update Date:2008-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO108134207RG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
G97365Medicare UPIN