Healthcare Provider Details

I. General information

NPI: 1801862065
Provider Name (Legal Business Name): LASER & DERMATOLOGIC SURGERY CENTER, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/27/2006
Last Update Date: 02/13/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1001 CHESTERFIELD PKWY E SUITE 101
CHESTERFIELD MO
63017-2041
US

IV. Provider business mailing address

1001 CHESTERFIELD PKWY E SUITE 101
CHESTERFIELD MO
63017-2041
US

V. Phone/Fax

Practice location:
  • Phone: 314-878-3839
  • Fax: 314-878-6575
Mailing address:
  • Phone: 314-878-3839
  • Fax: 314-878-6575

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207ND0101X
TaxonomyMOHS-Micrographic Surgery Physician
License NumberR6H14
License Number StateMO

VIII. Authorized Official

Name: MR. SCOTT RADLE
Title or Position: PRACTICE MANAGER
Credential: BS HEALTHCARE ADMIN
Phone: 314-878-3839