Provider Demographics
NPI:1871044735
Name:SUSAN D PURCELL MD DERMATOLOGY LLC
Entity type:Organization
Organization Name:SUSAN D PURCELL MD DERMATOLOGY LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:D
Authorized Official - Last Name:PURCELL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:314-985-8000
Mailing Address - Street 1:969 N MASON RD STE 170
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63141-6387
Mailing Address - Country:US
Mailing Address - Phone:314-985-8000
Mailing Address - Fax:314-985-8004
Practice Address - Street 1:969 N MASON RD STE 170
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63141-6387
Practice Address - Country:US
Practice Address - Phone:314-888-5305
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-10-16
Last Update Date:2016-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2008007453261QM2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
1831244904OtherNPI