Healthcare Provider Details

I. General information

NPI: 1285078154
Provider Name (Legal Business Name): EDWARD JUSTIN DERRICK MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/23/2013
Last Update Date: 08/24/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

510 S KINGSHIGHWAY BLVD
SAINT LOUIS MO
63110-1016
US

IV. Provider business mailing address

9500 EUCLID AVE
CLEVELAND OH
44195-0001
US

V. Phone/Fax

Practice location:
  • Phone: 314-362-7200
  • Fax: 314-747-4189
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number2018006395
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number35.137034
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: