Provider Demographics
NPI:1932299344
Name:KOTH, KURT (CRNA)
Entity Type:Individual
Prefix:
First Name:KURT
Middle Name:
Last Name:KOTH
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:55 WESTPORT PLZ
Mailing Address - Street 2:STE 300
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63146-3109
Mailing Address - Country:US
Mailing Address - Phone:314-548-4706
Mailing Address - Fax:314-548-4747
Practice Address - Street 1:232 S WOODS MILL RD
Practice Address - Street 2:
Practice Address - City:CHESTERFIELD
Practice Address - State:MO
Practice Address - Zip Code:63017
Practice Address - Country:US
Practice Address - Phone:314-205-6917
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-14
Last Update Date:2008-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO070178367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO912804572Medicaid
MO015060242Medicare ID - Type Unspecified