Provider Demographics
NPI:1063414704
Name:KENNETT PEDIATRICS AND ADOLESCENTS MEDICINE LLC
Entity type:Organization
Organization Name:KENNETT PEDIATRICS AND ADOLESCENTS MEDICINE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MD OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ANDREW
Authorized Official - Middle Name:C
Authorized Official - Last Name:BEACH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:573-888-0001
Mailing Address - Street 1:PO BOX 908
Mailing Address - Street 2:
Mailing Address - City:KENNETT
Mailing Address - State:MO
Mailing Address - Zip Code:63857-0908
Mailing Address - Country:US
Mailing Address - Phone:573-888-0001
Mailing Address - Fax:573-888-0006
Practice Address - Street 1:211 TEACO RD
Practice Address - Street 2:
Practice Address - City:KENNETT
Practice Address - State:MO
Practice Address - Zip Code:63857-3236
Practice Address - Country:US
Practice Address - Phone:573-888-0001
Practice Address - Fax:573-888-0006
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-12
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO208000000X
261QR1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
No208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO599371408Medicaid