Healthcare Provider Details

I. General information

NPI: 1396159091
Provider Name (Legal Business Name): DANIELA HERMELIN M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/20/2014
Last Update Date: 02/05/2021
Certification Date: 02/05/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1402 S GRAND BLVD
SAINT LOUIS MO
63104-1004
US

IV. Provider business mailing address

1402 S GRAND BLVD
SAINT LOUIS MO
63104-1004
US

V. Phone/Fax

Practice location:
  • Phone: 314-977-4547
  • Fax: 314-977-7615
Mailing address:
  • Phone: 314-577-8475
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207ZP0102X
TaxonomyAnatomic Pathology & Clinical Pathology Physician
License Number2018001272
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: