Healthcare Provider Details

I. General information

NPI: 1003918665
Provider Name (Legal Business Name): PETER M KILBRIDGE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/03/2006
Last Update Date: 07/20/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 CHILDRENS PL SUITE C
SAINT LOUIS MO
63110-1002
US

IV. Provider business mailing address

1 CHILDRENS PL C B 8116
SAINT LOUIS MO
63110-1002
US

V. Phone/Fax

Practice location:
  • Phone: 314-454-2479
  • Fax: 314-454-2524
Mailing address:
  • Phone: 314-454-2479
  • Fax: 314-454-2524

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number2006022621
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: