Basic Information
| Provider Information | |||||||||
| NPI: | 1114903507 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KICHURA | ||||||||
| FirstName: | GEORGE | ||||||||
| MiddleName: | M | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 11155 DUNN RD | ||||||||
| Address2: | SUITE 304E | ||||||||
| City: | SAINT LOUIS | ||||||||
| State: | MO | ||||||||
| PostalCode: | 631366150 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3147410911 | ||||||||
| FaxNumber: | 3146533671 | ||||||||
| Practice Location | |||||||||
| Address1: | 11155 DUNN RD | ||||||||
| Address2: | SUITE 304E | ||||||||
| City: | SAINT LOUIS | ||||||||
| State: | MO | ||||||||
| PostalCode: | 631366150 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3147410911 | ||||||||
| FaxNumber: | 3146533671 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/19/2005 | ||||||||
| LastUpdateDate: | 12/06/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 12/06/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RC0000X | R7H84 | MO | N | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease | 207RC0000X | 036-089747 | IL | N | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease | 207RI0011X | 036089474 | IL | N | Allopathic & Osteopathic Physicians | Internal Medicine | Interventional Cardiology | 207RI0011X | R7H84 | MO | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Interventional Cardiology |
ID Information
| ID | Type | State | Issuer | Description | 207725672 | 05 | MO | MEDICAID | 65466808 | 05 | IL | MEDICAID |