MEDICARE: KENYATTA D NORMAN M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207X00000X	Orthopaedic Surgery Physician	036128850	IL

General Provider Information

NPI Number	:	1659562528
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KENYATTA D NORMAN M.D.

Provider Business Mailing Address
First Line	:	1209 WASHINGTON AVE
Second Line	:	STE 518
City	:	SAINT LOUIS
State	:	MO
Zip	:	63103-1996
Country	:	US
Telephone Number	:	317-345-7518
Fax Number	:

Provider Business Practice Location Address
First Line	:	1209 WASHINGTON AVE
Second Line	:	STE 518
City	:	SAINT LOUIS
State	:	MO
Zip	:	63103-1996
Country	:	US
Telephone Number	:	317-345-7518
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/06/2007
Last Update Date	:	02/05/2014

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