Provider Demographics
NPI: | 1598761231 |
---|---|
Name: | KUNKEL, GLENN A (MD) |
Entity Type: | Individual |
Prefix: | |
First Name: | GLENN |
Middle Name: | A |
Last Name: | KUNKEL |
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: | P.O. BOX 1216 |
Mailing Address - Street 2: | |
Mailing Address - City: | ROLLA |
Mailing Address - State: | MO |
Mailing Address - Zip Code: | 65402 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 573-364-2200 |
Mailing Address - Fax: | 573-364-7600 |
Practice Address - Street 1: | 1000 W 10TH ST |
Practice Address - Street 2: | |
Practice Address - City: | ROLLA |
Practice Address - State: | MO |
Practice Address - Zip Code: | 65401-2905 |
Practice Address - Country: | US |
Practice Address - Phone: | 573-458-8899 |
Practice Address - Fax: | 573-341-5611 |
Is Sole Proprietor?: | No |
Enumeration Date: | 2005-06-27 |
Last Update Date: | 2023-11-02 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
MO | 113756 | 208VP0000X, 207L00000X, 174400000X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 207L00000X | Allopathic & Osteopathic Physicians | Anesthesiology | |
No | 208VP0000X | Allopathic & Osteopathic Physicians | Pain Medicine | Pain Medicine |
No | 174400000X | Other Service Providers | Specialist |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
MO | 209664002 | Medicaid | |
MO | F30586 | Medicare UPIN | |
MO | 209664002 | Medicaid |