Healthcare Provider Details

I. General information

NPI: 1417307505
Provider Name (Legal Business Name): KENT ALEXANDER NEIL CASSMEYER MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/20/2016
Last Update Date: 08/28/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 WINDING WOODS DR STE 214
O FALLON MO
63366-4773
US

IV. Provider business mailing address

300 WINDING WOODS DR STE 214
O FALLON MO
63366-4773
US

V. Phone/Fax

Practice location:
  • Phone: 636-614-3289
  • Fax: 636-272-3680
Mailing address:
  • Phone: 636-614-3289
  • Fax: 636-272-3680

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number2019024541
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: