Provider Demographics
NPI:1083694087
Name:BURKEMPER, NICOLE M (MD)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:M
Last Name:BURKEMPER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1008 S SPRING AVE FL 3
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63110-2520
Mailing Address - Country:US
Mailing Address - Phone:314-977-1771
Mailing Address - Fax:317-977-1802
Practice Address - Street 1:1225 S GRAND BLVD FL 3
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63104-1016
Practice Address - Country:US
Practice Address - Phone:314-977-3400
Practice Address - Fax:314-977-7613
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-18
Last Update Date:2021-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN44829207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN530633700Medicaid
MN530633700Medicaid
MN070000609Medicare ID - Type Unspecified
H66616Medicare UPIN