Healthcare Provider Details

I. General information

NPI: 1124052808
Provider Name (Legal Business Name): KYLE C MOYLAN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/10/2006
Last Update Date: 07/15/2025
Certification Date: 12/23/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4901 FOREST PARK AVE DIV IM PALLIATIVE MED, STE 241
SAINT LOUIS MO
63108-1495
US

IV. Provider business mailing address

PO BOX 7412011
CHICAGO IL
60674-2011
US

V. Phone/Fax

Practice location:
  • Phone: 314-747-5361
  • Fax: 314-747-5357
Mailing address:
  • Phone: 314-747-5361
  • Fax: 314-747-5357

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number2001027314
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code207RH0002X
TaxonomyHospice and Palliative Medicine (Internal Medicine) Physician
License Number2001027314
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: