Healthcare Provider Details

I. General information

NPI: 1124634449
Provider Name (Legal Business Name): REDBIRD PEDIATRICS, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/22/2020
Last Update Date: 03/02/2021
Certification Date: 03/02/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

793 SUNSET BLVD
O FALLON IL
62269-1960
US

IV. Provider business mailing address

793 SUNSET BLVD
O FALLON IL
62269-1960
US

V. Phone/Fax

Practice location:
  • Phone: 618-668-2473
  • Fax:
Mailing address:
  • Phone: 618-668-2473
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State

VIII. Authorized Official

Name: KEVIN PONCIROLI
Title or Position: PEDIATRICIAN
Credential: MD
Phone: 618-668-2473