Healthcare Provider Details

I. General information

NPI: 1598761231
Provider Name (Legal Business Name): GLENN A. KUNKEL MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/27/2005
Last Update Date: 11/02/2023
Certification Date: 11/02/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1000 W 10TH ST
ROLLA MO
65401-2905
US

IV. Provider business mailing address

P.O. BOX 1216
ROLLA MO
65402
US

V. Phone/Fax

Practice location:
  • Phone: 573-458-8899
  • Fax: 573-341-5611
Mailing address:
  • Phone: 573-364-2200
  • Fax: 573-364-7600

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License Number113756
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number113756
License Number StateMO
# 3
Primary TaxonomyN
Taxonomy Code208VP0000X
TaxonomyPain Medicine Physician
License Number113756
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: