Provider Demographics
NPI:1962518605
Name:PURTELL, JAMES NORBERT (MD)
Entity type:Individual
Prefix:
First Name:JAMES
Middle Name:NORBERT
Last Name:PURTELL
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 1:10004 KENNERLY RD
Mailing Address - Street 2:
Mailing Address - City:ST LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63128
Mailing Address - Country:US
Mailing Address - Phone:314-849-6850
Mailing Address - Fax:314-849-6851
Practice Address - Street 1:10004 KENNERLY RD
Practice Address - Street 2:
Practice Address - City:ST LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63128
Practice Address - Country:US
Practice Address - Phone:314-849-6850
Practice Address - Fax:314-849-6851
Is Sole Proprietor?:No
Enumeration Date:2006-08-23
Last Update Date:2010-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO58808207R00000X, 207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO200661947Medicaid
MO000001519Medicare ID - Type Unspecified
MO200661947Medicaid