MEDICARE: DR. GEORGE M KICHURA M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207RC0000X	Cardiovascular Disease Physician	R7H84	MO
2	207RC0000X	Cardiovascular Disease Physician	036-089747	IL
3	207RI0011X	Interventional Cardiology Physician	036089474	IL
4	207RI0011X	Interventional Cardiology Physician	R7H84	MO

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1114903507
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. GEORGE M KICHURA M.D.

Provider Business Mailing Address
First Line	:	11155 DUNN RD
Second Line	:	SUITE 304E
City	:	SAINT LOUIS
State	:	MO
Zip	:	63136-6150
Country	:	US
Telephone Number	:	314-741-0911
Fax Number	:	314-653-3671

Provider Business Practice Location Address
First Line	:	11155 DUNN RD
Second Line	:	SUITE 304E
City	:	SAINT LOUIS
State	:	MO
Zip	:	63136-6150
Country	:	US
Telephone Number	:	314-741-0911
Fax Number	:	314-653-3671

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/19/2005
Last Update Date	:	12/06/2021

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Directions to “ DR. GEORGE M KICHURA M.D.” Practice Location

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