Healthcare Provider Details

I. General information

NPI: 1932299344
Provider Name (Legal Business Name): KURT KOTH CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/14/2006
Last Update Date: 09/08/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

232 S WOODS MILL RD
CHESTERFIELD MO
63017
US

IV. Provider business mailing address

55 WESTPORT PLZ STE 300
SAINT LOUIS MO
63146-3109
US

V. Phone/Fax

Practice location:
  • Phone: 314-205-6917
  • Fax:
Mailing address:
  • Phone: 314-548-4706
  • Fax: 314-548-4747

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number070178
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: