MEDICARE: KAMAL R DEMETRY M.D.

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	207P00000X	Emergency Medicine Physician	ME83088	FL
2	207P00000X	Emergency Medicine Physician	105483	MO
3	207P00000X	Emergency Medicine Physician	036-094350	IL
4	207R00000X	Internal Medicine Physician	105483	MO

General Provider Information

NPI Number	:	1174548549
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KAMAL R DEMETRY M.D.

Provider Business Mailing Address
First Line	:	4438 TELEGRAPH RD
Second Line	:
City	:	SAINT LOUIS
State	:	MO
Zip	:	63129-3316
Country	:	US
Telephone Number	:	314-742-6000
Fax Number	:

Provider Business Practice Location Address
First Line	:	4438 TELEGRAPH RD
Second Line	:
City	:	SAINT LOUIS
State	:	MO
Zip	:	63129-3316
Country	:	US
Telephone Number	:	314-742-6000
Fax Number	:

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

Provider Enumeration Date	:	07/13/2006
Last Update Date	:	02/09/2022

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