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General NPI Number Information
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NPI Number | 1437667920
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Entity Type | Organization
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Legal Business Name | ST. LOUIS DERMATOLOGY CENTER LLC
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Dates
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Enumeration Date | 01/18/2018
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Last Update Date | 01/18/2018
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Provider Practice Location Address
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Address Line | 8888 LADUE RD STE 210
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City | SAINT LOUIS
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State | MO
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Zip | 63124-2056
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Country | US
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Telephone | 314-474-0114
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Fax | 314-526-2686
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Provider Business Mailing Address
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Address Line | 536 ROSEDALE AVE APT 201
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City | SAINT LOUIS
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State | MO
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Zip | 63112-1427
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Country | US
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Telephone | 334-221-2357
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | OSAMUEDE OSEMWOTA
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Credential | MD
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Telephone | 314-474-0114
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207N00000X
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Taxonomy Name | Dermatology Physician
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License Number | 2017039492
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License Number State | MO
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