Provider Demographics
NPI:1831244904
Name:PURCELL, SUSAN DERAMO (MD)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:DERAMO
Last Name:PURCELL
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:969 N MASON RD
Mailing Address - Street 2:SUITE 235
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63141-6338
Mailing Address - Country:US
Mailing Address - Phone:314-469-3333
Mailing Address - Fax:314-469-3327
Practice Address - Street 1:969 N MASON RD
Practice Address - Street 2:SUITE 235
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63141-6338
Practice Address - Country:US
Practice Address - Phone:314-469-3333
Practice Address - Fax:314-469-3327
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-25
Last Update Date:2008-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2008007453207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology