Provider Demographics
NPI:1114903507
Name:KICHURA, GEORGE M (MD)
Entity Type:Individual
Prefix:DR
First Name:GEORGE
Middle Name:M
Last Name:KICHURA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:11155 DUNN RD
Mailing Address - Street 2:SUITE 304E
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63136-6150
Mailing Address - Country:US
Mailing Address - Phone:314-741-0911
Mailing Address - Fax:314-653-3671
Practice Address - Street 1:11155 DUNN RD
Practice Address - Street 2:SUITE 304E
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63136-6150
Practice Address - Country:US
Practice Address - Phone:314-741-0911
Practice Address - Fax:314-653-3671
Is Sole Proprietor?:No
Enumeration Date:2005-12-19
Last Update Date:2021-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOR7H84207RC0000X, 207RI0011X
IL036-089747207RC0000X
IL036089474207RI0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional Cardiology
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO207725672Medicaid
IL65466808Medicaid