Provider Demographics
NPI:1124060975
Name:TRIMMER, KENNETH BRYAN (DO)
Entity type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:BRYAN
Last Name:TRIMMER
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3023 N BALLAS RD STE 200D
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63131-2328
Mailing Address - Country:US
Mailing Address - Phone:314-996-7272
Mailing Address - Fax:
Practice Address - Street 1:3023 N BALLAS RD STE 200D
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63131-2328
Practice Address - Country:US
Practice Address - Phone:314-996-7272
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-12
Last Update Date:2021-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOR8D06207RC0000X, 207RI0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional Cardiology
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO242012102Medicaid
A10566Medicare UPIN
A10566Medicare UPIN
003013022Medicare ID - Type UnspecifiedFARMINGTON NUMBER