Healthcare Provider Details

I. General information

NPI: 1306948930
Provider Name (Legal Business Name): SRIPATT KULKAMTHORN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/03/2006
Last Update Date: 12/07/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8710 MANCHESTER RD
SAINT LOUIS MO
63144-2724
US

IV. Provider business mailing address

PO BOX 1239
TROY MI
48099-1239
US

V. Phone/Fax

Practice location:
  • Phone: 314-961-3570
  • Fax: 314-961-6450
Mailing address:
  • Phone: 248-824-6600
  • Fax: 248-324-1477

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number35018
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number35018
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: