Provider Demographics
NPI:1437667920
Name:ST. LOUIS DERMATOLOGY CENTER LLC
Entity Type:Organization
Organization Name:ST. LOUIS DERMATOLOGY CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:OSAMUEDE
Authorized Official - Middle Name:
Authorized Official - Last Name:OSEMWOTA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:314-474-0114
Mailing Address - Street 1:536 ROSEDALE AVE APT 201
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63112-1427
Mailing Address - Country:US
Mailing Address - Phone:334-221-2357
Mailing Address - Fax:
Practice Address - Street 1:8888 LADUE RD STE 210
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63124-2056
Practice Address - Country:US
Practice Address - Phone:314-474-0114
Practice Address - Fax:314-526-2686
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-01-18
Last Update Date:2018-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2017039492207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty