Basic Information
| Provider Information | |||||||||
| NPI: | 1982777413 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | DERMATOLOGY AT WINGHAVEN, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5551 WINGHAVEN BLVD | ||||||||
| Address2: | STE 210 | ||||||||
| City: | O FALLON | ||||||||
| State: | MO | ||||||||
| PostalCode: | 633683617 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6365614613 | ||||||||
| FaxNumber: | 6365614610 | ||||||||
| Practice Location | |||||||||
| Address1: | 5551 WINGHAVEN BLVD | ||||||||
| Address2: | STE 210 | ||||||||
| City: | O FALLON | ||||||||
| State: | MO | ||||||||
| PostalCode: | 633683617 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6365614613 | ||||||||
| FaxNumber: | 6365614610 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/15/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | QUALLEY | ||||||||
| AuthorizedOfficialFirstName: | RACHEL | ||||||||
| AuthorizedOfficialMiddleName: | M | ||||||||
| AuthorizedOfficialTitleorPosition: | PHYSICIAN,OWNER | ||||||||
| AuthorizedOfficialTelephone: | 6365614613 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | 2004011011 | MO | Y | 193400000X SINGLE SPECIALTY GROUP | Other Service Providers | Specialist |
No ID Information.