Provider Demographics
NPI:1730352394
Name:FIRST CAPITOL DERMATOLOGY, L.L.C.
Entity type:Organization
Organization Name:FIRST CAPITOL DERMATOLOGY, L.L.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN/OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:HENRY
Authorized Official - Middle Name:W
Authorized Official - Last Name:CLEVER
Authorized Official - Suffix:III
Authorized Official - Credentials:MD
Authorized Official - Phone:636-916-1300
Mailing Address - Street 1:901 S. 5TH ST.
Mailing Address - Street 2:FIRST CAPITOL DERMATOLOGY, L.L.C.
Mailing Address - City:ST. CHARLES
Mailing Address - State:MO
Mailing Address - Zip Code:63301-2416
Mailing Address - Country:US
Mailing Address - Phone:636-916-1300
Mailing Address - Fax:636-916-1561
Practice Address - Street 1:901 S. 5TH ST.
Practice Address - Street 2:FIRST CAPITOL DERMATOLOGY, L.L.C.
Practice Address - City:ST. CHARLES
Practice Address - State:MO
Practice Address - Zip Code:63301-2416
Practice Address - Country:US
Practice Address - Phone:636-916-1300
Practice Address - Fax:636-916-1561
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-03
Last Update Date:2017-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOR4P68207ND0101X
R4P68207ND0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207ND0101XAllopathic & Osteopathic PhysiciansDermatologyMOHS-Micrographic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO203348628Medicaid
MO074225734Medicare PIN
MOE86947Medicare UPIN
E86947Medicare UPIN
MO203348628Medicaid