Provider Demographics
NPI:1508850314
Name:KAIRUZ, BARTOLOME C (MD)
Entity Type:Individual
Prefix:DR
First Name:BARTOLOME
Middle Name:C
Last Name:KAIRUZ
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 1:10004 KENNERLY RD
Mailing Address - Street 2:SUITE 115A
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63128-2141
Mailing Address - Country:US
Mailing Address - Phone:314-843-4444
Mailing Address - Fax:314-843-8599
Practice Address - Street 1:10004 KENNERLY RD
Practice Address - Street 2:SUITE 115A
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63128-2141
Practice Address - Country:US
Practice Address - Phone:314-843-4444
Practice Address - Fax:314-843-8599
Is Sole Proprietor?:No
Enumeration Date:2005-09-07
Last Update Date:2011-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO31482207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO31482OtherSTATE LICENSE
MO200739308Medicaid
MO080885656Medicare PIN
MO200739308Medicaid