Healthcare Provider Details

I. General information

NPI: 1386745115
Provider Name (Legal Business Name): KEVIN R MAHONEY MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/26/2006
Last Update Date: 09/22/2025
Certification Date: 09/22/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1225 S GRAND BLVD LEVEL 2
SAINT LOUIS MO
63104-1016
US

IV. Provider business mailing address

1008 S SPRING AVE STE 1615
SAINT LOUIS MO
63110-2520
US

V. Phone/Fax

Practice location:
  • Phone: 314-977-4440
  • Fax: 314-977-1877
Mailing address:
  • Phone: 314-977-4717
  • Fax: 314-977-1877

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RC0200X
TaxonomyCritical Care Medicine (Internal Medicine) Physician
License Number43940
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number43940
License Number StateWI
# 3
Primary TaxonomyY
Taxonomy Code2086S0127X
TaxonomyTrauma Surgery Physician
License Number2007020558
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: