1003832221 NPI number — DR. CARL G KLUTKE MD

Table of content: DR. CARL G KLUTKE MD (NPI 1003832221)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1003832221 NPI number — DR. CARL G KLUTKE MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KLUTKE
Provider First Name:
CARL
Provider Middle Name:
G
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1003832221
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/16/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
660 S EUCLID AVE
Provider Second Line Business Mailing Address:
C B 8242
Provider Business Mailing Address City Name:
SAINT LOUIS
Provider Business Mailing Address State Name:
MO
Provider Business Mailing Address Postal Code:
63110-1010
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
314-996-8060
Provider Business Mailing Address Fax Number:
314-747-4871

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1040 N MASON RD
Provider Second Line Business Practice Location Address:
STE 122
Provider Business Practice Location Address City Name:
SAINT LOUIS
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
63141-6399
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
314-996-8060
Provider Business Practice Location Address Fax Number:
314-747-4871
Provider Enumeration Date:
07/14/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 208800000X , with the licence number:  R1K30 , registered in the state of MO ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: P01808689 . This is a "CLEAR HEALTH ALLIANCE" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 1193315 . This is a "WELLCARE" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 017010219 , issued by the state of ( MO ) . This identifiers is of the category "MEDICAID".
  • Identifier: 105605200 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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