Healthcare Provider Details

I. General information

NPI: 1568473510
Provider Name (Legal Business Name): KENNETH HALL REGIONAL HOSPITAL, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/11/2006
Last Update Date: 12/10/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

129 N 8TH ST
EAST SAINT LOUIS IL
62201-2917
US

IV. Provider business mailing address

1836 LACKLAND HILL PKWY
SAINT LOUIS MO
63146-3572
US

V. Phone/Fax

Practice location:
  • Phone: 618-482-7044
  • Fax: 618-482-7018
Mailing address:
  • Phone: 314-872-1439
  • Fax: 314-810-1399

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code207RP1001X
TaxonomyPulmonary Disease Physician
License Number
License Number StateIL
# 3
Primary TaxonomyN
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License Number
License Number StateIL
# 4
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number
License Number StateIL

VIII. Authorized Official

Name: MR. MICHAEL MCMANUS
Title or Position: COO
Credential:
Phone: 618-332-5212