Unknown Individual – Pediatrics Physician, NPI 1164423935
Pediatrics Physician
Main info
Profile Insights
NPPES metrics only — not quality of care.
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Provider Addresses for Unknown Individual
PO BOX 908
KENNETT, MO 638570908
Phone: (573) 888-0001
Fax: (573) 888-0006
Type: Mailing
211, Teaco Road, Kennett, Dunklin County, Missouri, 63857, United States
KENNETT, MO 638573236
Phone: (573) 888-0001
Fax: (573) 888-0006
Type: Location
NPPES updates history
No NPPES updates recorded for this provider.
Prescription Activity
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Open Payments (CMS)
CMS reports 12 Open Payments records for all available years, with a total value of $210.
Total Amount is formed as General ($210) + Research ($0) + Ownership ($0) = $210.
Last reported payment date: 2024-10-11 • Largest payer in this snapshot: Merck Sharp & Dohme LLC ($100).
Total Amount
$210
General + Research + Ownership
Payments
12
Total payment records
General Amount
$210
General payments
Research Amount
$0
Research funding
Ownership Amount
$0
Ownership interests
Ownership Count
0
Ownership records
Last Payment Date
2024-10-11
Latest reported date
Top Companies
Largest payers in this snapshot
| Company | Amount |
|---|---|
| Merck Sharp & Dohme LLC | $100 |
| SANOFI PASTEUR INC. | $35 |
| Supernus Pharmaceuticals, Inc. | $34 |
| Tris Pharma Inc | $19 |
| GlaxoSmithKline, LLC. | $13 |
Medicare Enrollment & Revalidation
Source: CMS public data · Not endorsed by CMS ·
Educational use only—not medical, billing, or legal advice.
Medicare revalidation (CMS due date list)
Past revalidation due date
Earliest CMS due date was 2024-05-31 (742 days ago).
Enrollment records
1
Earliest due date
2024-05-31
CMS data updated
2026-06-01
Revalidation progress
- Medicare enrolled
- On CMS revalidation list
- Due date assigned
- Revalidate in PECOS
CMS enrollment records
| Enrollment ID | Type | Specialty | State | Due date |
|---|---|---|---|---|
| O20090106000522 | O | Rural Health Clinic | MO | 2024-05-31 |
What to do next
- Verify current status on the CMS Revalidation Lookup Tool immediately.
- Complete revalidation in PECOS or contact your Medicare Administrative Contractor (MAC).
- Overdue revalidation can lead to deactivation of Medicare billing privileges.
Prepare CMS-855 application → · Look up this NPI in PECOS → · Verify on CMS PECOS
Medicare Utilization (FFS)
Source: CMS public data · Not endorsed by CMS · Beneficiary counts under 11 are suppressed in source data ·
Educational use only—not medical, billing, or legal advice.
No Medicare fee-for-service utilization data available for this provider in our database.
Insurance plans in this area (ZIP 63857)
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