Basic Information
| Provider Information | |||||||||
| NPI: | 1902897127 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KISSEL | ||||||||
| FirstName: | JOHN | ||||||||
| MiddleName: | |||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 23340 | ||||||||
| Address2: | |||||||||
| City: | SAINT LOUIS | ||||||||
| State: | MO | ||||||||
| PostalCode: | 631563340 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3148511075 | ||||||||
| FaxNumber: | 3148514445 | ||||||||
| Practice Location | |||||||||
| Address1: | 1027 BELLEVUE AVE | ||||||||
| Address2: | SUITE 107 | ||||||||
| City: | SAINT LOUIS | ||||||||
| State: | MO | ||||||||
| PostalCode: | 631171851 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3146453743 | ||||||||
| FaxNumber: | 3146477967 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/04/2005 | ||||||||
| LastUpdateDate: | 01/28/2008 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | R6264 | MO | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 0400459 | 01 | MO | UHC | OTHER | 182164 | 01 | MO | HEALTHLINK | OTHER | 21840 | 01 | MO | BCBS | OTHER | A13796 | 01 | MO | MERCY | OTHER | 000000010020 | 01 | MO | ESSENCE | OTHER | 127446 | 01 | MO | GHP | OTHER | 4414064 | 01 | MO | AETNA | OTHER |