Provider Demographics
NPI:1902378250
Name:MERAMEC DERMATOLOGY LLC
Entity Type:Organization
Organization Name:MERAMEC DERMATOLOGY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PARTNER
Authorized Official - Prefix:DR
Authorized Official - First Name:KARL
Authorized Official - Middle Name:WILLIAM
Authorized Official - Last Name:STASER
Authorized Official - Suffix:
Authorized Official - Credentials:MD, PHD
Authorized Official - Phone:317-910-5487
Mailing Address - Street 1:3783 VOGEL RD
Mailing Address - Street 2:
Mailing Address - City:ARNOLD
Mailing Address - State:MO
Mailing Address - Zip Code:63010-6202
Mailing Address - Country:US
Mailing Address - Phone:636-751-0995
Mailing Address - Fax:866-783-0115
Practice Address - Street 1:3783 VOGEL RD
Practice Address - Street 2:
Practice Address - City:ARNOLD
Practice Address - State:MO
Practice Address - Zip Code:63010-6202
Practice Address - Country:US
Practice Address - Phone:636-751-0995
Practice Address - Fax:866-783-0115
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-12-27
Last Update Date:2019-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO1992144174Medicaid
MO1942615265Medicaid