Provider Demographics
NPI:1235761438
Name:ST CHARLES COUNTY DERMATOLOGIC SURGERY, LLC
Entity Type:Organization
Organization Name:ST CHARLES COUNTY DERMATOLOGIC SURGERY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN AND OWNER
Authorized Official - Prefix:
Authorized Official - First Name:STACEY
Authorized Official - Middle Name:S
Authorized Official - Last Name:TULL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:636-327-3376
Mailing Address - Street 1:1493 COTTLEVILLE PKWY
Mailing Address - Street 2:
Mailing Address - City:COTTLEVILLE
Mailing Address - State:MO
Mailing Address - Zip Code:63376-3564
Mailing Address - Country:US
Mailing Address - Phone:636-317-3376
Mailing Address - Fax:636-244-1197
Practice Address - Street 1:1493 COTTLEVILLE PKWY
Practice Address - Street 2:
Practice Address - City:COTTLEVILLE
Practice Address - State:MO
Practice Address - Zip Code:63376-3564
Practice Address - Country:US
Practice Address - Phone:636-317-3376
Practice Address - Fax:636-244-1197
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-02-06
Last Update Date:2020-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207NS0135XAllopathic & Osteopathic PhysiciansDermatologyProcedural DermatologyGroup - Single Specialty