Provider Demographics
NPI:1760662514
Name:SKIN SURGERY CENTER OF MISSOURI, LLC
Entity type:Organization
Organization Name:SKIN SURGERY CENTER OF MISSOURI, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:SAADIA
Authorized Official - Middle Name:TAUFIQ
Authorized Official - Last Name:RAZA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:314-276-0385
Mailing Address - Street 1:6704 KEATON CORPORATE PKWY
Mailing Address - Street 2:
Mailing Address - City:O FALLON
Mailing Address - State:MO
Mailing Address - Zip Code:63368-8680
Mailing Address - Country:US
Mailing Address - Phone:636-300-9596
Mailing Address - Fax:636-300-9598
Practice Address - Street 1:6704 KEATON CORPORATE PKWY STE 100
Practice Address - Street 2:
Practice Address - City:O FALLON
Practice Address - State:MO
Practice Address - Zip Code:63368-8680
Practice Address - Country:US
Practice Address - Phone:636-300-9596
Practice Address - Fax:636-300-9598
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-09
Last Update Date:2021-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO207NS0135X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207NS0135XAllopathic & Osteopathic PhysiciansDermatologyProcedural DermatologyGroup - Single Specialty