Healthcare Provider Details

I. General information

NPI: 1609960509
Provider Name (Legal Business Name): COLUMBIA DERMATOLOGY, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/03/2006
Last Update Date: 09/05/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

401 N KEENE ST
COLUMBIA MO
65201-6625
US

IV. Provider business mailing address

401 N KEENE ST
COLUMBIA MO
65201-6625
US

V. Phone/Fax

Practice location:
  • Phone: 573-876-1616
  • Fax: 573-876-1678
Mailing address:
  • Phone: 573-876-1616
  • Fax: 573-876-1678

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207ND0101X
TaxonomyMOHS-Micrographic Surgery Physician
License Number107883
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number107883
License Number StateMO

VIII. Authorized Official

Name: LINDALL A. PERRY
Title or Position: PRESIDENT
Credential: M.D.
Phone: 573-876-1616