Provider Demographics
NPI:1306948930
Name:KULKAMTHORN, SRIPATT (MD)
Entity type:Individual
Prefix:
First Name:SRIPATT
Middle Name:
Last Name:KULKAMTHORN
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 1239
Mailing Address - Street 2:
Mailing Address - City:TROY
Mailing Address - State:MI
Mailing Address - Zip Code:48099-1239
Mailing Address - Country:US
Mailing Address - Phone:248-824-6600
Mailing Address - Fax:248-324-1477
Practice Address - Street 1:8710 MANCHESTER RD
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63144-2724
Practice Address - Country:US
Practice Address - Phone:314-961-3570
Practice Address - Fax:314-961-6450
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-03
Last Update Date:2011-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO35018207Q00000X, 208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO0004000577OtherAETNA
MO327602073KULOtherMERCY HEALTH PLAN
MO3542OtherHEALTHCARE USA PROVIDER #
MO2365237OtherCIGNA
MO115186OtherHEALTHLINK
MO201098019Medicaid
MO01003230OtherUNITED HEALTHCARE
MO431280201OtherAETNA
MOA09758OtherCMR
MO32901OtherMISSOURI BC/BS
MO45992OtherGROUP HEALTH PLAN
MO0004000577OtherAETNA
MO01003230OtherUNITED HEALTHCARE