Healthcare Provider Details

I. General information

NPI: 1831172451
Provider Name (Legal Business Name): SERIN PHRUTTITUM MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/29/2005
Last Update Date: 11/12/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12680 OLIVE BLVD SUITE 300
CREVE COEUR MO
63141-6322
US

IV. Provider business mailing address

12680 OLIVE BLVD SUITE 300
CREVE COEUR MO
63141-6322
US

V. Phone/Fax

Practice location:
  • Phone: 314-251-8888
  • Fax: 314-251-8889
Mailing address:
  • Phone: 314-251-8888
  • Fax: 314-251-8889

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number4301070810
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number108455
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: