NPIMap

Organization Active NPI

Redbird Pediatrics, PLLC

  • Pediatrics Physician
  • O'Fallon, IL
National Provider Identifier
1124634449
Registry record updated Mar 2, 2021
On this page

Key facts

NPPES NPI Registry
Primary specialty
Pediatrics PhysicianTaxonomy code 208000000X
Legal business name
REDBIRD PEDIATRICS, PLLC
Practice address
793 Sunset Blvd
O Fallon, IL 62269-1960
Phone
(618) 668-2473
NPI assigned
Sep 22, 2020
Last updated
Mar 2, 2021By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Mar 2, 2021

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

Authorized official

Name
Kevin Ponciroli, MDNPI 1598776411
Title
Pediatrician
Phone
(618) 668-2473

Authorized official NPPES reports the official by name only. The link goes to the one practitioner connected to this organization with that name.

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Pediatrics Physician 208000000X NU Primary

Addresses

Primary practice location

793 Sunset Blvd
O Fallon, IL 62269-1960

Mailing address

793 Sunset Blvd
O Fallon, IL 62269-1960
Phone (618) 668-2473

Other practice location 1

914 Red Scarlet Ct
Shiloh, IL 62221-8306
Phone (618) 972-7422

Other identifiers 1

IdentifierTypeStateIssuer
1598776411MedicaidIL

Laboratory certificates & supplier records

Derived by NPIMap

These CMS records do not include an NPI. They are shown because their name and street address match this provider’s.

CLIA laboratory certificates

CLIA numberLaboratoryCertificateExpires
14D2205128Redbird Pediatrics793 Sunset Blvd, O Fallon, IL 62269Certificate of waiverDec 11, 2026

National Provider Directory

National Provider Directory

Interoperability endpoints

  • FHIR API: https://api.platform.athenahealth.com/22493/brand/1/csg/1/fhir/r4

Practitioners & affiliated clinicians

Practitioners 5

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

NPI Registry JSON

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

{
    "created_epoch": "1600732800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1614643200000",
    "number": "1124634449",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "793 SUNSET BLVD",
            "city": "O FALLON",
            "state": "IL",
            "postal_code": "622691960",
            "telephone_number": "618-668-2473"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "793 SUNSET BLVD",
            "city": "O FALLON",
            "state": "IL",
            "postal_code": "622691960",
            "telephone_number": "618-668-2473"
        }
    ],
    "practiceLocations": [
        {
            "address_1": "914 Red Scarlet Ct",
            "address_purpose": "LOCATION",
            "city": "Shiloh",
            "state": "IL",
            "postal_code": "622218306",
            "country_code": "US",
            "telephone_number": "618-972-7422",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "basic": {
        "organization_name": "REDBIRD PEDIATRICS, PLLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2020-09-22",
        "last_updated": "2021-03-02",
        "certification_date": "2021-03-02",
        "status": "A",
        "authorized_official_last_name": "PONCIROLI",
        "authorized_official_first_name": "KEVIN",
        "authorized_official_title_or_position": "PEDIATRICIAN",
        "authorized_official_telephone_number": "618-668-2473",
        "authorized_official_credential": "MD"
    },
    "taxonomies": [
        {
            "code": "208000000X",
            "taxonomy_group": "",
            "desc": "Pediatrics",
            "state": "NU",
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "1598776411",
            "state": "IL"
        }
    ],
    "endpoints": [],
    "other_names": []
}

Other providers in O'Fallon, IL

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Mar 2, 2021; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • Medicare Care Compare (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.