Provider Demographics
NPI:1013954676
Name:SOUTHEAST MISSOURI DERMATOLOGY, PC
Entity Type:Organization
Organization Name:SOUTHEAST MISSOURI DERMATOLOGY, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DARRELL
Authorized Official - Middle Name:L
Authorized Official - Last Name:GRIFFIN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:573-760-8811
Mailing Address - Street 1:1223 MAPLE ST
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON
Mailing Address - State:MO
Mailing Address - Zip Code:63640-7616
Mailing Address - Country:US
Mailing Address - Phone:573-760-8811
Mailing Address - Fax:573-760-8844
Practice Address - Street 1:1223 MAPLE ST
Practice Address - Street 2:
Practice Address - City:FARMINGTON
Practice Address - State:MO
Practice Address - Zip Code:63640-7616
Practice Address - Country:US
Practice Address - Phone:573-760-8811
Practice Address - Fax:573-760-8844
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-01
Last Update Date:2014-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MODE9856Medicare PIN
MO000015472Medicare PIN