Provider Demographics
NPI:1881613347
Name:BRIGHTFIELD, KENNETH R (MD)
Entity type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:R
Last Name:BRIGHTFIELD
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 1:12855 N 40 DR
Mailing Address - Street 2:SUITE 280
Mailing Address - City:ST. LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63141
Mailing Address - Country:US
Mailing Address - Phone:314-432-4415
Mailing Address - Fax:314-432-1986
Practice Address - Street 1:12855 N 40 DR
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63141-8657
Practice Address - Country:US
Practice Address - Phone:314-432-4415
Practice Address - Fax:314-432-1986
Is Sole Proprietor?:No
Enumeration Date:2006-07-18
Last Update Date:2014-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOR5C32207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
P00616024OtherRAILROAD MEDICARE
MOP01134545OtherRAILROAD MEDICARE
MO152800109Medicare PIN
MOP01134545OtherRAILROAD MEDICARE
133640004Medicare PIN
MOA28728Medicare UPIN