Provider Demographics
NPI:1780625384
Name:KRIN, CHARLES S (DO)
Entity type:Individual
Prefix:
First Name:CHARLES
Middle Name:S
Last Name:KRIN
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4425 RIDGE DR
Mailing Address - Street 2:
Mailing Address - City:HIGH RIDGE
Mailing Address - State:MO
Mailing Address - Zip Code:63049-1906
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2620 N WESTWOOD BLVD
Practice Address - Street 2:
Practice Address - City:POPLAR BLUFF
Practice Address - State:MO
Practice Address - Zip Code:63901-3396
Practice Address - Country:US
Practice Address - Phone:573-785-7721
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2005035774207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOPENDINGMedicaid
D74113Medicare UPIN
MOPENDINGMedicare ID - Type Unspecified