Provider Demographics
NPI:1124052808
Name:MOYLAN, KYLE C (MD)
Entity type:Individual
Prefix:
First Name:KYLE
Middle Name:C
Last Name:MOYLAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 23340
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63156-3340
Mailing Address - Country:US
Mailing Address - Phone:314-467-1500
Mailing Address - Fax:314-467-1515
Practice Address - Street 1:1011 BOWLES AVE
Practice Address - Street 2:SUITE 450
Practice Address - City:FENTON
Practice Address - State:MO
Practice Address - Zip Code:63026-2395
Practice Address - Country:US
Practice Address - Phone:314-467-1500
Practice Address - Fax:314-467-1515
Is Sole Proprietor?:No
Enumeration Date:2006-07-10
Last Update Date:2020-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2001027314207RG0300X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO209080407Medicaid
MO209080OtherBLUE CHOICE
MO543164OtherHEALTHLINK
MOH85013Medicare UPIN
MO902621444Medicare PIN
MO209080407Medicaid
MO209080OtherBLUE CHOICE