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General NPI Number Information
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NPI Number | 1649255894
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Entity Type | Organization
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Legal Business Name | GLENN A KUNKEL MD LLC
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Dates
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Enumeration Date | 12/09/2005
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 1000 W 10TH ST
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City | ROLLA
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State | MO
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Zip | 65401-2905
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Country | US
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Telephone | 660-826-5960
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Fax | 660-826-4852
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Provider Business Mailing Address
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Address Line | PO BOX 1547
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City | SEDALIA
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State | MO
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Zip | 65302-1547
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Country | US
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Telephone | 660-826-5960
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Fax | 660-826-4852
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Authorized Official
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Title or Position | OWNER
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Name | DR. GLENN A KUNKEL
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Credential | MD
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Telephone | 660-826-5960
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207LP2900X
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Taxonomy Name | Pain Medicine (Anesthesiology) Physician
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License Number | 113756
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License Number State | MO
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