Provider Demographics
NPI:1134143761
Name:SKIN PATHOLOGY LLC
Entity Type:Organization
Organization Name:SKIN PATHOLOGY LLC
Other - Org Name:ACADEMY OF SKIN PATHOLOGY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:XIAO-DONG
Authorized Official - Middle Name:
Authorized Official - Last Name:WANG
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:314-522-8896
Mailing Address - Street 1:6944 N HANLEY RD
Mailing Address - Street 2:
Mailing Address - City:HAZELWOOD
Mailing Address - State:MO
Mailing Address - Zip Code:63042-2933
Mailing Address - Country:US
Mailing Address - Phone:314-522-8896
Mailing Address - Fax:
Practice Address - Street 1:6944 N HANLEY RD
Practice Address - Street 2:
Practice Address - City:HAZELWOOD
Practice Address - State:MO
Practice Address - Zip Code:63042-2933
Practice Address - Country:US
Practice Address - Phone:314-522-8896
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-27
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2002014408207ZD0900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207ZD0900XAllopathic & Osteopathic PhysiciansPathologyDermatopathologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOH62370Medicare UPIN