Individual
MESUD DEDIC
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Contact information
Practice address
4500 MEMORIAL DR, BELLEVILLE, IL 62226-5360
(618) 233-7750
Mailing address
1951 GREENPOINT DR APT 304, SAINT LOUIS, MO 63122-5241
Taxonomy
Speciality
Code
Description
License number
State
163WC0200X
Critical Care Medicine Registered Nurse
041506786
IL
163WC0200X
Critical Care Medicine Registered Nurse
2017023122
MO
367500000X
Certified Registered Nurse Anesthetist
Primary
209029939
IL
390200000X
Student in an Organized Health Care Education/Training Program
—
—
Other
Enumeration date
07/31/2023
Last updated
06/28/2024
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