Healthcare Provider Details

I. General information

NPI: 1265675771
Provider Name (Legal Business Name): KIMBELL KORNU M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/14/2009
Last Update Date: 03/12/2021
Certification Date: 03/12/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1201 S GRAND BLVD
SAINT LOUIS MO
63104-1016
US

IV. Provider business mailing address

1008 S SPRING AVE FL 2
SAINT LOUIS MO
63110-2520
US

V. Phone/Fax

Practice location:
  • Phone: 314-977-8462
  • Fax:
Mailing address:
  • Phone: 314-977-8462
  • Fax: 314-977-3370

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberMD0000047954
License Number StateTN
# 2
Primary TaxonomyY
Taxonomy Code207RH0002X
TaxonomyHospice and Palliative Medicine (Internal Medicine) Physician
License Number2015012454
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: