Healthcare Provider Details

I. General information

NPI: 1417123761
Provider Name (Legal Business Name): PERRY KIDS PEDIATRICS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/07/2008
Last Update Date: 05/07/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

210 HOSPITAL LN
PERRYVILLE MO
63775-1276
US

IV. Provider business mailing address

210 HOSPITAL LANE
PERRYVILLE MO
63670
UM

V. Phone/Fax

Practice location:
  • Phone: 573-517-0999
  • Fax: 573-517-0812
Mailing address:
  • Phone: 573-517-0999
  • Fax: 543-517-0812

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080T0002X
TaxonomyPediatric Medical Toxicology Physician
License NumberMO105937
License Number StateMO

VIII. Authorized Official

Name: DR. BHARGAV M KANANI
Title or Position: ADMINISTRATOR
Credential: M.D.
Phone: 573-517-0999