MEDICARE: DR. KELLY N BOTTERON MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2084P0804X	Child & Adolescent Psychiatry Physician	R3P75	MO

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1013952860
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. KELLY N BOTTERON MD

Provider Business Mailing Address
First Line	:	4511 FOREST PARK AVE
Second Line	:	STE 4300
City	:	SAINT LOUIS
State	:	MO
Zip	:	63108-2138
Country	:	US
Telephone Number	:	314-286-1700
Fax Number	:	314-408-2756

Provider Business Practice Location Address
First Line	:	4444 FOREST PARK AVE
Second Line	:	STE 2600
City	:	SAINT LOUIS
State	:	MO
Zip	:	63108-2212
Country	:	US
Telephone Number	:	314-286-1700
Fax Number	:	314-286-1777

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/17/2006
Last Update Date	:	11/15/2021

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Directions to “ DR. KELLY N BOTTERON MD” Practice Location

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