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
StateLicense IDTaxonomies
MO113756208VP0000X, 207L00000X, 174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
No208VP0000XAllopathic & Osteopathic PhysiciansPain MedicinePain Medicine
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO209664002Medicaid
MOF30586Medicare UPIN
MO209664002Medicaid