Healthcare Provider Details

I. General information

NPI: 1568813863
Provider Name (Legal Business Name): AARON JACOB RUSSELL MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/28/2016
Last Update Date: 04/17/2025
Certification Date: 02/03/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

969 N MASON RD DIV IM DERMATOLOGY, STE 220
SAINT LOUIS MO
63141-6282
US

IV. Provider business mailing address

PO BOX 7412011
CHICAGO IL
60674-2011
US

V. Phone/Fax

Practice location:
  • Phone: 314-273-3376
  • Fax: 888-682-0525
Mailing address:
  • Phone: 314-273-3376
  • Fax: 888-682-0525

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number2021011092
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code207ZD0900X
TaxonomyDermatopathology (Pathology) Physician
License Number2021011092
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: