Basic Information
| Provider Information | |||||||||
| NPI: | 1831172451 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PHRUTTITUM | ||||||||
| FirstName: | SERIN | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 12680 OLIVE BLVD | ||||||||
| Address2: | SUITE 300 | ||||||||
| City: | CREVE COEUR | ||||||||
| State: | MO | ||||||||
| PostalCode: | 631416322 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3142518888 | ||||||||
| FaxNumber: | 3142518889 | ||||||||
| Practice Location | |||||||||
| Address1: | 12680 OLIVE BLVD | ||||||||
| Address2: | SUITE 300 | ||||||||
| City: | CREVE COEUR | ||||||||
| State: | MO | ||||||||
| PostalCode: | 631416322 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3142518888 | ||||||||
| FaxNumber: | 3142518889 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/29/2005 | ||||||||
| LastUpdateDate: | 11/12/2014 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 4301070810 | MI | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | 108455 | MO | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 1399189 | 01 | MO | AETNA PPO | OTHER | 283073 | 01 | MO | GHP | OTHER | 431771217 | 01 | MO | BCE EMERGIS (MULTIPLAN) | OTHER | 431771217 | 01 | MO | CHOICE CARE HPPO/HUMANA | OTHER | 431771217 | 01 | MO | UP&UP | OTHER | 750900066 | 01 | MO | BNDD | OTHER | 0108537 | 01 | MO | SECURE HORIZONS | OTHER | 1399189 | 01 | MO | AETNA | OTHER | 2067362 | 01 | MO | UNITED HEALTHCARE SELECT | OTHER | 431771217 | 01 | MO | CCN PPO | OTHER | 431771217 | 01 | MO | GREAT WEST | OTHER | 431771217 | 01 | MO | HEALTH NETWORK | OTHER | P00623861 | 01 | MO | RAILROAD MEDICARE | OTHER | 431771217 | 01 | MO | PROAMERICA | OTHER | 209864 | 01 | MO | BC/BS PLANS | OTHER | 431771217 | 01 | MO | HFN PPO | OTHER | 431771217 | 01 | MO | UNICARE PPO | OTHER | 65230 | 01 | MO | HEATHCARE USA | OTHER | 755719 | 01 | MO | HEALTHLINK | OTHER | 2067362 | 01 | MO | UNITED HEALTHCARE PPO/POS | OTHER | 208486118 | 05 | MO | MEDICAID | 431771217 | 01 | MO | VETERAN'S ADMIN | OTHER | 700632 | 01 | MO | MERCYCARE PLUS | OTHER | 7797806 | 01 | MO | CIGNA | OTHER | H10214 | 01 | MO | MERCY HEALTHPLAN | OTHER | 431771217 | 01 | MO | PHCS PPO/POS | OTHER |