Provider Demographics
NPI:1689817322
Name:MIDWEST DERMAL SPECIALIST
Entity Type:Organization
Organization Name:MIDWEST DERMAL SPECIALIST
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:TAMMIE
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:AUER
Authorized Official - Suffix:
Authorized Official - Credentials:REGISTERED NURSE
Authorized Official - Phone:314-954-5568
Mailing Address - Street 1:1423 VILLAS ESTATES DR
Mailing Address - Street 2:
Mailing Address - City:FENTON
Mailing Address - State:MO
Mailing Address - Zip Code:63026-3284
Mailing Address - Country:US
Mailing Address - Phone:314-954-5568
Mailing Address - Fax:636-825-9568
Practice Address - Street 1:1423 VILLAS ESTATES DR
Practice Address - Street 2:
Practice Address - City:FENTON
Practice Address - State:MO
Practice Address - Zip Code:63026-3284
Practice Address - Country:US
Practice Address - Phone:314-954-5568
Practice Address - Fax:636-825-9568
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-04-10
Last Update Date:2009-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO132832251J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251J00000XAgenciesNursing Care