Provider Demographics
NPI:1295913028
Name:MID-COUNTY DERMATOLOGY, INC
Entity type:Organization
Organization Name:MID-COUNTY DERMATOLOGY, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:DR
Authorized Official - First Name:CONNIE
Authorized Official - Middle Name:
Authorized Official - Last Name:GIBSTINE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:314-994-0200
Mailing Address - Street 1:3009 N BALLAS RD
Mailing Address - Street 2:STE 208B
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63131-2322
Mailing Address - Country:US
Mailing Address - Phone:314-994-0200
Mailing Address - Fax:314-994-7945
Practice Address - Street 1:3009 N BALLAS RD
Practice Address - Street 2:STE 208B
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63131-2322
Practice Address - Country:US
Practice Address - Phone:314-994-0200
Practice Address - Fax:314-994-7945
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-04
Last Update Date:2009-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO000012915OtherMEDICARE LEGACY NUMBER