MEDICARE: GUILLERMO COUCHONNAL MD, LLC

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	207RI0200X	Infectious Disease Physician	0417557	KS

General Provider Information

NPI Number	:	1346495942
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GUILLERMO COUCHONNAL MD, LLC

Provider Business Mailing Address
First Line	:	1836 LACKLAND HILL PKWY
Second Line	:
City	:	SAINT LOUIS
State	:	MO
Zip	:	63146-3572
Country	:	US
Telephone Number	:	314-872-1439
Fax Number	:	314-810-1399

Provider Business Practice Location Address
First Line	:	6013 LEAVENWORTH RD
Second Line	:
City	:	KANSAS CITY
State	:	KS
Zip	:	66104-1436
Country	:	US
Telephone Number	:	816-942-4755
Fax Number	:	816-942-1581

Authorized Official
Title or Position	:	OWNER
Name	:	DR. GUILLERMO COUCHONNAL
Credential	:	MD
Telephone Number	:	816-942-4755

Provider Enumeration Date	:	11/24/2008
Last Update Date	:	11/24/2008

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