Provider Demographics
NPI:1790734994
Name:GOURTZELIS, NICHOLAS (MD)
Entity Type:Individual
Prefix:
First Name:NICHOLAS
Middle Name:
Last Name:GOURTZELIS
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:PO BOX 802841
Mailing Address - Street 2:
Mailing Address - City:KANSAS CITY
Mailing Address - State:MO
Mailing Address - Zip Code:64180-2841
Mailing Address - Country:US
Mailing Address - Phone:314-842-9669
Mailing Address - Fax:314-842-1017
Practice Address - Street 1:10004 KENNERLY RD
Practice Address - Street 2:STE 374B
Practice Address - City:ST LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63128
Practice Address - Country:US
Practice Address - Phone:314-842-9669
Practice Address - Fax:314-842-1017
Is Sole Proprietor?:No
Enumeration Date:2006-05-08
Last Update Date:2024-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2005006931207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO207376708Medicaid
MO207376708Medicaid
MO929693431Medicare ID - Type Unspecified