Healthcare Provider Details

I. General information

NPI: 1831234400
Provider Name (Legal Business Name): MICHAEL E MCCADDEN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/21/2007
Last Update Date: 07/16/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

621 S NEW BALLAS RD 498A
SAINT LOUIS MO
63141-8232
US

IV. Provider business mailing address

2 CARLSON PKWY N STE 240
PLYMOUTH MN
55447-4485
US

V. Phone/Fax

Practice location:
  • Phone: 314-251-3376
  • Fax: 314-251-5781
Mailing address:
  • Phone: 314-251-3376
  • Fax: 314-251-5781

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207NS0135X
TaxonomyProcedural Dermatology Physician
License NumberMDR4H54
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License NumberMDR4H54
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: