Provider Demographics
NPI:1831172451
Name:PHRUTTITUM, SERIN (MD)
Entity type:Individual
Prefix:DR
First Name:SERIN
Middle Name:
Last Name:PHRUTTITUM
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 1:12680 OLIVE BLVD
Mailing Address - Street 2:SUITE 300
Mailing Address - City:CREVE COEUR
Mailing Address - State:MO
Mailing Address - Zip Code:63141-6322
Mailing Address - Country:US
Mailing Address - Phone:314-251-8888
Mailing Address - Fax:314-251-8889
Practice Address - Street 1:12680 OLIVE BLVD
Practice Address - Street 2:SUITE 300
Practice Address - City:CREVE COEUR
Practice Address - State:MO
Practice Address - Zip Code:63141-6322
Practice Address - Country:US
Practice Address - Phone:314-251-8888
Practice Address - Fax:314-251-8889
Is Sole Proprietor?:No
Enumeration Date:2005-11-29
Last Update Date:2014-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301070810207Q00000X
MO108455207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO1399189OtherAETNA PPO
MO283073OtherGHP
MO431771217OtherBCE EMERGIS (MULTIPLAN)
MO431771217OtherCHOICE CARE HPPO/HUMANA
MO431771217OtherUP&UP
MO750900066OtherBNDD
MO0108537OtherSECURE HORIZONS
MO1399189OtherAETNA
MO2067362OtherUNITED HEALTHCARE SELECT
MO431771217OtherCCN PPO
MO431771217OtherGREAT WEST
MO431771217OtherHEALTH NETWORK
MOP00623861OtherRAILROAD MEDICARE
MO431771217OtherPROAMERICA
MO209864OtherBC/BS PLANS
MO431771217OtherHFN PPO
MO431771217OtherUNICARE PPO
MO65230OtherHEATHCARE USA
MO755719OtherHEALTHLINK
MO2067362OtherUNITED HEALTHCARE PPO/POS
MO208486118Medicaid
MO431771217OtherVETERAN'S ADMIN
MO700632OtherMERCYCARE PLUS
MO7797806OtherCIGNA
MOH10214OtherMERCY HEALTHPLAN
MO431771217OtherPHCS PPO/POS
MO1399189OtherAETNA
MO750900066OtherBNDD
MOH10214Medicare UPIN