1003929407 NPI number — SSM DEPAUL MEDICAL GROUP, INC.

Table of content: SPENCER JAMES LLOYD D.M.D. (NPI 1558371377)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1003929407 NPI number — SSM DEPAUL MEDICAL GROUP, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SSM DEPAUL MEDICAL GROUP, INC.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1003929407
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
12255 DE PAUL DR
Provider Second Line Business Mailing Address:
SUITE 200
Provider Business Mailing Address City Name:
BRIDGETON
Provider Business Mailing Address State Name:
MO
Provider Business Mailing Address Postal Code:
63044-2510
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
314-344-7600
Provider Business Mailing Address Fax Number:
314-344-7850

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
12255 DE PAUL DR
Provider Second Line Business Practice Location Address:
SUITE 200
Provider Business Practice Location Address City Name:
BRIDGETON
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
63044-2510
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
314-344-7600
Provider Business Practice Location Address Fax Number:
314-344-7850
Provider Enumeration Date:
08/17/2006

Additional Information

Authorized Official

Authorized Official Last Name:
PULLUM
Authorized Official First Name:
LAURA
Authorized Official Middle Name:
LYNN
Authorized Official Title or Position:
DIRECTOR OF PATIENT ACCOUNTS
Authorized Official Telephone Number:
314-209-8121

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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