MEDICARE: DR. KENNETH WAYNE KLESH 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	2080N0001X	Neonatal-Perinatal Medicine Physician	R8G17	MO

General Provider Information

NPI Number	:	1447213178
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. KENNETH WAYNE KLESH M.D.

Provider Business Mailing Address
First Line	:	18108 BENT RIDGE DR
Second Line	:
City	:	WILDWOOD
State	:	MO
Zip	:	63038-1435
Country	:	US
Telephone Number	:	636-458-4177
Fax Number	:

Provider Business Practice Location Address
First Line	:	621 S NEW BALLAS RD
Second Line	:
City	:	SAINT LOUIS
State	:	MO
Zip	:	63141-8241
Country	:	US
Telephone Number	:	314-251-5860
Fax Number	:	314-251-5861

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

Provider Enumeration Date	:	04/12/2006
Last Update Date	:	07/08/2007

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