1760810543 NPI number — ST LOUIS DERMATOLOGY LLC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1760810543 NPI number — ST LOUIS DERMATOLOGY LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ST LOUIS DERMATOLOGY LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1760810543
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/18/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1011 BOWLES AVENUE
Provider Second Line Business Mailing Address:
SUITE 121
Provider Business Mailing Address City Name:
FENTON
Provider Business Mailing Address State Name:
MO
Provider Business Mailing Address Postal Code:
63026-2387
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
314-200-2713
Provider Business Mailing Address Fax Number:
314-200-2714

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1011 BOWLES AVENUE
Provider Second Line Business Practice Location Address:
SUITE 121
Provider Business Practice Location Address City Name:
FENTON
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
63026-2387
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
314-200-2713
Provider Business Practice Location Address Fax Number:
314-200-2714
Provider Enumeration Date:
10/14/2013

Additional Information

Authorized Official

Authorized Official Last Name:
PETERSEN
Authorized Official First Name:
JEFFREY
Authorized Official Middle Name:
E
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
314-200-2713

Provider Taxonomy Codes

  • Taxonomy code: 207N00000X , with the licence number:  2001020599 , registered in the state of MO ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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