NPIMap

Organization Active NPI

Kennett Pediatrics and Adolescents Medicine LLC

  • Rural Health Clinic/Center
  • Kennett, MO
National Provider Identifier
1063414704
Registry record updated Jul 21, 2022
On this page

Key facts

NPPES NPI Registry
Primary specialty
Rural Health Clinic/CenterTaxonomy code 261QR1300X
Legal business name
KENNETT PEDIATRICS AND ADOLESCENTS MEDICINE LLC
Practice address
211 Teaco Rd
Kennett, MO 63857-3236
Phone
(573) 888-0001
Fax
(573) 888-0006
NPI assigned
Aug 12, 2005
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Jul 21, 2022

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Andrew C Beach, MD
Title
MD Owner
Phone
(573) 888-0001

Specialties & licenses 2

Specialty (taxonomy)CodeLicenseStatePrimary
Pediatrics PhysicianGroup: 193400000X SINGLE SPECIALTY GROUP 208000000X MO
Rural Health Clinic/Center 261QR1300X Primary

Addresses

Primary practice location

211 Teaco Rd
Kennett, MO 63857-3236

Mailing address

PO Box 908
Kennett, MO 63857-0908
Phone (573) 888-0001

Other identifiers 1

IdentifierTypeStateIssuer
599371408MedicaidMO

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Not listed in the public Medicare enrollment file

Rural health clinic certification: CCN 263960

Name & address match This certification has no NPI in the Medicare enrollment files. CMS publishes enrollment files for six facility types only, so it was connected to this NPI by matching the name and address CMS publishes for it.

Legal name
KENNETT PEDIATRICS AND ADOLESC
Certification status
Active
Provider type (POS)
Rural health clinic
Participating since
Apr 17, 2003
Last certification
Oct 9, 2019
Ownership / control type
1A
Facility address
211 Teaco Road PO Box 908
Kennett, MO 63857

National Provider Directory

National Provider Directory
Tax ID family
Kennett Pediatrics and Asolescents Medicine LLC3 organizations share this tax ID, including this one

Other organizations with this tax ID 2

Organizations that report the same tax identification number in the National Provider Directory.

Practitioners & affiliated clinicians

Practitioners 1

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1123804800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1658361600000",
    "number": "1063414704",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PO BOX 908",
            "city": "KENNETT",
            "state": "MO",
            "postal_code": "638570908",
            "telephone_number": "573-888-0001",
            "fax_number": "573-888-0006"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "211 TEACO RD",
            "city": "KENNETT",
            "state": "MO",
            "postal_code": "638573236",
            "telephone_number": "573-888-0001",
            "fax_number": "573-888-0006"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "KENNETT PEDIATRICS AND ADOLESCENTS MEDICINE LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2005-08-12",
        "last_updated": "2022-07-21",
        "status": "A",
        "authorized_official_last_name": "BEACH",
        "authorized_official_first_name": "ANDREW",
        "authorized_official_middle_name": "C",
        "authorized_official_title_or_position": "MD OWNER",
        "authorized_official_telephone_number": "573-888-0001",
        "authorized_official_credential": "MD"
    },
    "taxonomies": [
        {
            "code": "208000000X",
            "taxonomy_group": "193400000X SINGLE SPECIALTY  GROUP",
            "desc": "Pediatrics",
            "state": "MO",
            "license": null,
            "primary": false
        },
        {
            "code": "261QR1300X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Rural Health",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "599371408",
            "state": "MO"
        }
    ],
    "endpoints": [],
    "other_names": []
}

Other providers in Kennett, MO

Sources for this page

Verify at the official NPI Registry.