Healthcare Provider Details

I. General information

NPI: 1134873185
Provider Name (Legal Business Name): ST. LOUIS DERMATOLOGY & COSMETIC SURGERY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/08/2022
Last Update Date: 05/10/2026
Certification Date: 05/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

520 E CHERRY ST
TROY MO
63379-1410
US

IV. Provider business mailing address

7354 MARYLAND AVE
SAINT LOUIS MO
63130-4201
US

V. Phone/Fax

Practice location:
  • Phone: 314-834-1400
  • Fax: 314-834-1430
Mailing address:
  • Phone: 314-834-1400
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207NP0225X
TaxonomyPediatric Dermatology Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code207NS0135X
TaxonomyProcedural Dermatology Physician
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code207ND0900X
TaxonomyDermatopathology Physician
License Number
License Number State
# 5
Primary TaxonomyY
Taxonomy Code207ND0101X
TaxonomyMOHS-Micrographic Surgery Physician
License Number
License Number State

VIII. Authorized Official

Name: BRANDON BEAL
Title or Position: MEDICAL DIRECTOR
Credential: MD
Phone: 314-422-6882