Provider Demographics
NPI:1659304061
Name:ST. LOUIS DERMATOLOGY AND SURGERY CENTER, PC
Entity Type:Organization
Organization Name:ST. LOUIS DERMATOLOGY AND SURGERY CENTER, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PARTNER
Authorized Official - Prefix:
Authorized Official - First Name:JAEYOUNG
Authorized Official - Middle Name:
Authorized Official - Last Name:YOON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:314-520-7919
Mailing Address - Street 1:200 DENE DR
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:MO
Mailing Address - Zip Code:65201-6598
Mailing Address - Country:US
Mailing Address - Phone:573-446-6400
Mailing Address - Fax:
Practice Address - Street 1:12855 N 40 DR
Practice Address - Street 2:SUITE 180
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63141-8635
Practice Address - Country:US
Practice Address - Phone:314-878-5599
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-09
Last Update Date:2012-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207ND0101XAllopathic & Osteopathic PhysiciansDermatologyMOHS-Micrographic SurgeryGroup - Single Specialty