Healthcare Provider Details

I. General information

NPI: 1508120528
Provider Name (Legal Business Name): EDWARD WILLIAM KUNTZ M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/25/2012
Last Update Date: 05/30/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4500 MEMORIAL DR
BELLEVILLE IL
62226-5360
US

IV. Provider business mailing address

4949 ITASKA ST
SAINT LOUIS MO
63109-2912
US

V. Phone/Fax

Practice location:
  • Phone: 618-233-7750
  • Fax:
Mailing address:
  • Phone: 314-255-8524
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number036140024
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: