Provider Demographics
NPI:1225022718
Name:KONZELMANN, HENRY JOSEPH (MD)
Entity type:Individual
Prefix:DR
First Name:HENRY
Middle Name:JOSEPH
Last Name:KONZELMANN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 366
Mailing Address - Street 2:
Mailing Address - City:STE GENEVIEVE
Mailing Address - State:MO
Mailing Address - Zip Code:63670-0366
Mailing Address - Country:US
Mailing Address - Phone:217-827-3114
Mailing Address - Fax:
Practice Address - Street 1:800 STE GENEVIEVE DR
Practice Address - Street 2:
Practice Address - City:STE GENEVIEVE
Practice Address - State:MO
Practice Address - Zip Code:63670-1434
Practice Address - Country:US
Practice Address - Phone:573-883-4438
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-09-09
Last Update Date:2023-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036095900207P00000X, 207Q00000X
MO2013002805207Q00000X, 207PE0004X
IN01069387A207Q00000X
TXP6438207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207PE0004XAllopathic & Osteopathic PhysiciansEmergency MedicineEmergency Medical Services
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL0360900Medicaid
IL036095900OtherLICENSE #
IL0360900Medicaid
IL0360900Medicaid