Provider Demographics
NPI:1679514095
Name:KENNETH GERDES , LLC
Entity type:Organization
Organization Name:KENNETH GERDES , LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLING MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:JACKI
Authorized Official - Middle Name:
Authorized Official - Last Name:JORDAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:314-432-2580
Mailing Address - Street 1:PO BOX 1209
Mailing Address - Street 2:
Mailing Address - City:MARYLAND HEIGHTS
Mailing Address - State:MO
Mailing Address - Zip Code:63043-0209
Mailing Address - Country:US
Mailing Address - Phone:314-432-2580
Mailing Address - Fax:314-991-8960
Practice Address - Street 1:11155 DUNN RD
Practice Address - Street 2:SUITE 211N
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63136-6150
Practice Address - Country:US
Practice Address - Phone:314-432-2580
Practice Address - Fax:314-991-8960
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-09
Last Update Date:2024-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO117124174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO500745609Medicaid
MODE2084OtherRR MCR GROUP PROV#
MO500745609Medicaid