Provider Demographics
NPI:1760810543
Name:ST LOUIS DERMATOLOGY LLC
Entity Type:Organization
Organization Name:ST LOUIS DERMATOLOGY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:E
Authorized Official - Last Name:PETERSEN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:314-200-2713
Mailing Address - Street 1:1011 BOWLES AVENUE
Mailing Address - Street 2:SUITE 121
Mailing Address - City:FENTON
Mailing Address - State:MO
Mailing Address - Zip Code:63026-2387
Mailing Address - Country:US
Mailing Address - Phone:314-200-2713
Mailing Address - Fax:314-200-2714
Practice Address - Street 1:1011 BOWLES AVENUE
Practice Address - Street 2:SUITE 121
Practice Address - City:FENTON
Practice Address - State:MO
Practice Address - Zip Code:63026-2387
Practice Address - Country:US
Practice Address - Phone:314-200-2713
Practice Address - Fax:314-200-2714
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-10-14
Last Update Date:2014-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2001020599207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty