Provider Demographics
NPI:1801862065
Name:LASER & DERMATOLOGIC SURGERY CENTER, INC.
Entity Type:Organization
Organization Name:LASER & DERMATOLOGIC SURGERY CENTER, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:SCOTT
Authorized Official - Middle Name:
Authorized Official - Last Name:RADLE
Authorized Official - Suffix:
Authorized Official - Credentials:BS HEALTHCARE ADMIN
Authorized Official - Phone:314-878-3839
Mailing Address - Street 1:1001 CHESTERFIELD PKWY E
Mailing Address - Street 2:SUITE 101
Mailing Address - City:CHESTERFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:63017-2041
Mailing Address - Country:US
Mailing Address - Phone:314-878-3839
Mailing Address - Fax:314-878-6575
Practice Address - Street 1:1001 CHESTERFIELD PKWY E
Practice Address - Street 2:SUITE 101
Practice Address - City:CHESTERFIELD
Practice Address - State:MO
Practice Address - Zip Code:63017-2041
Practice Address - Country:US
Practice Address - Phone:314-878-3839
Practice Address - Fax:314-878-6575
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-02-27
Last Update Date:2012-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOR6H14207ND0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207ND0101XAllopathic & Osteopathic PhysiciansDermatologyMOHS-Micrographic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO000013092Medicare ID - Type UnspecifiedMEDICARE GROUP NUMBER
MO4393320001Medicare NSC