Healthcare Provider Details

I. General information

NPI: 1245475482
Provider Name (Legal Business Name): DR RAFI KEVORKIAN LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/02/2008
Last Update Date: 12/09/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3760 S LINDBERGH BLVD SUITE 101
SAINT LOUIS MO
63127-1358
US

IV. Provider business mailing address

3760 S LINDBERGH BLVD SUITE 101
SAINT LOUIS MO
63127-1358
US

V. Phone/Fax

Practice location:
  • Phone: 636-634-5865
  • Fax: 314-849-5716
Mailing address:
  • Phone: 636-634-5865
  • Fax: 314-849-5716

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RG0300X
TaxonomyGeriatric Medicine (Internal Medicine) Physician
License Number108134
License Number StateMO

VIII. Authorized Official

Name: DR. RAFI T KEVORKIAN
Title or Position: PRESIDENT
Credential: MD
Phone: 636-634-5865