Provider Demographics
NPI:1770713950
Name:ADVANCED DERMATOLOGY OF SOUTHEAST MISSOURI PC
Entity type:Organization
Organization Name:ADVANCED DERMATOLOGY OF SOUTHEAST MISSOURI PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:MORRIS
Authorized Official - Last Name:MOON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:573-335-7546
Mailing Address - Street 1:1359 N MOUNT AUBURN RD
Mailing Address - Street 2:
Mailing Address - City:CAPE GIRARDEAU
Mailing Address - State:MO
Mailing Address - Zip Code:63701-1727
Mailing Address - Country:US
Mailing Address - Phone:573-335-7546
Mailing Address - Fax:573-335-7550
Practice Address - Street 1:2116 MEGAN DR STE 102
Practice Address - Street 2:
Practice Address - City:CAPE GIRARDEAU
Practice Address - State:MO
Practice Address - Zip Code:63701-1979
Practice Address - Country:US
Practice Address - Phone:573-335-7546
Practice Address - Fax:573-335-7550
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-07-22
Last Update Date:2021-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2007038037207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty