Provider Demographics
NPI:1538374384
Name:WOODS MILL PEDIATRIC AND ADOLESCENT MEDICINE, LLC
Entity type:Organization
Organization Name:WOODS MILL PEDIATRIC AND ADOLESCENT MEDICINE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DOCTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:C
Authorized Official - Last Name:LEVY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:314-453-9666
Mailing Address - Street 1:226 S WOODS MILL RD
Mailing Address - Street 2:SUITE36W
Mailing Address - City:CHESTERFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:63017-3662
Mailing Address - Country:US
Mailing Address - Phone:314-453-9666
Mailing Address - Fax:314-453-9895
Practice Address - Street 1:226 S WOODS MILL RD
Practice Address - Street 2:SUITE36W
Practice Address - City:CHESTERFIELD
Practice Address - State:MO
Practice Address - Zip Code:63017-3662
Practice Address - Country:US
Practice Address - Phone:314-453-9666
Practice Address - Fax:314-453-9895
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-14
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty