Provider Demographics
NPI:1063555860
Name:KORENBLAT, PHILLIP ERWIN (MD)
Entity type:Individual
Prefix:DR
First Name:PHILLIP
Middle Name:ERWIN
Last Name:KORENBLAT
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 1:1040 N MASON RD
Mailing Address - Street 2:SUITE 112
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63141-6399
Mailing Address - Country:US
Mailing Address - Phone:314-514-8509
Mailing Address - Fax:314-542-0109
Practice Address - Street 1:1040 N MASON RD
Practice Address - Street 2:SUITE 112
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63141-6399
Practice Address - Country:US
Practice Address - Phone:314-514-8509
Practice Address - Fax:314-542-0109
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-14
Last Update Date:2016-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO18311OtherBLUE CROSS BLUE SHIELD
MOA12801Medicare UPIN
030000958OtherRAILROAD MEDICARE
MO502942402Medicaid
001011440Medicare PIN
MO119464OtherHEALTHLINK