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9915 Kennerly Rd Suite J Saint Louis MO 63128-2703 | |
| (314) 843-4794 | |
| (314) 843-9256 |
| Full Name | |
|---|---|
| Speciality | Internal Medicine |
| Location | 9915 Kennerly Rd, Saint Louis, Missouri |
| Authorized Official Name and Position | Charles J. Willey (OWNER/PHYSICIAN) |
| Authorized Official Contact | 3148434794 |
| Accepts Medicare Insurance | Yes. This clinic participates in medicare program and accept medicare insurance. |
| Mailing Address | Practice Location Address |
|---|---|
9915 Kennerly Rd Suite J Saint Louis MO 63128-2703 Ph: (314) 843-4794 | 9915 Kennerly Rd Suite J Saint Louis MO 63128-2703 Ph: (314) 843-4794 |
| NPI Number | 1477876423 |
|---|---|
| Provider Enumeration Date | 03/04/2010 |
| Last Update Date | 03/12/2020 |
| Medicare PECOS PAC ID | 9537293816 |
|---|---|
| Medicare Enrollment ID | O20100823000820 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1477876423 | NPI | - | NPPES |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 207R00000X | Internal Medicine | (Missouri) | Primary |
| Provider Name | Ehab Kaiser |
|---|---|
| Provider Type | Practitioner - Internal Medicine |
| Provider Identifiers | NPI Number: 1205804796 PECOS PAC ID: 6002863354 Enrollment ID: I20050407001105 |
| Provider Name | Becky J Ganz |
|---|---|
| Provider Type | Practitioner - Nurse Practitioner |
| Provider Identifiers | NPI Number: 1922208024 PECOS PAC ID: 8325130891 Enrollment ID: I20070828001128 |
| Provider Name | Charles Willey |
|---|---|
| Provider Type | Practitioner - Internal Medicine |
| Provider Identifiers | NPI Number: 1811996028 PECOS PAC ID: 0244205615 Enrollment ID: I20071203000615 |
| Provider Name | Erin M Holloway |
|---|---|
| Provider Type | Practitioner - Nurse Practitioner |
| Provider Identifiers | NPI Number: 1033369798 PECOS PAC ID: 6608936497 Enrollment ID: I20081124000734 |
| Provider Name | Paul B Vatterott |
|---|---|
| Provider Type | Practitioner - Internal Medicine |
| Provider Identifiers | NPI Number: 1346239381 PECOS PAC ID: 8628139441 Enrollment ID: I20081211000190 |
| Provider Name | Stephanie L Graham |
|---|---|
| Provider Type | Practitioner - Nurse Practitioner |
| Provider Identifiers | NPI Number: 1306238704 PECOS PAC ID: 5395065452 Enrollment ID: I20150513002389 |
| Provider Name | Albert Wayne Scrimsher |
|---|---|
| Provider Type | Practitioner - Nurse Practitioner |
| Provider Identifiers | NPI Number: 1972053833 PECOS PAC ID: 7517245962 Enrollment ID: I20161107000044 |
| Provider Name | Emil Trevis Fernando |
|---|---|
| Provider Type | Practitioner - Internal Medicine |
| Provider Identifiers | NPI Number: 1982968129 PECOS PAC ID: 2567787237 Enrollment ID: I20170130000111 |
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