Healthcare Provider Details

I. General information

NPI: 1790734994
Provider Name (Legal Business Name): NICHOLAS GOURTZELIS MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/08/2006
Last Update Date: 01/22/2024
Certification Date: 01/22/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10004 KENNERLY RD STE 374B
ST LOUIS MO
63128
US

IV. Provider business mailing address

PO BOX 802841
KANSAS CITY MO
64180-2841
US

V. Phone/Fax

Practice location:
  • Phone: 314-842-9669
  • Fax: 314-842-1017
Mailing address:
  • Phone: 314-842-9669
  • Fax: 314-842-1017

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License Number2005006931
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: