Healthcare Provider Details

I. General information

NPI: 1013916121
Provider Name (Legal Business Name): JOHN W. KILGORE M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/20/2005
Last Update Date: 01/05/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1027 BELLEVUE AVE SUITE 200
SAINT LOUIS MO
63117-1851
US

IV. Provider business mailing address

12855 N 40 DR SUITE 300
SAINT LOUIS MO
63141-8666
US

V. Phone/Fax

Practice location:
  • Phone: 314-645-6450
  • Fax: 314-645-2560
Mailing address:
  • Phone: 314-880-6100
  • Fax: 314-997-3248

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License NumberR9E12
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: