1518396670 NPI number — SSM ST CHARLES CLINIC MEDICAL GROUP

Table of content: (NPI 1518396670)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1518396670 NPI number — SSM ST CHARLES CLINIC MEDICAL GROUP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SSM ST CHARLES CLINIC MEDICAL GROUP
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:
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:
1518396670
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/08/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1551 WALL ST
Provider Second Line Business Mailing Address:
SUITE 310
Provider Business Mailing Address City Name:
SAINT CHARLES
Provider Business Mailing Address State Name:
MO
Provider Business Mailing Address Postal Code:
63303-3539
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
636-669-2268
Provider Business Mailing Address Fax Number:
314-209-8127

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
400 MEDICAL PLZ
Provider Second Line Business Practice Location Address:
SUITE 200
Provider Business Practice Location Address City Name:
LAKE ST LOUIS
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
63367-1490
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
636-625-2662
Provider Business Practice Location Address Fax Number:
636-625-1121
Provider Enumeration Date:
11/08/2013

Additional Information

Authorized Official

Authorized Official Last Name:
PULLUM
Authorized Official First Name:
LAURA
Authorized Official Middle Name:
Authorized Official Title or Position:
DIRECTOR
Authorized Official Telephone Number:
636-669-2434

Provider Taxonomy Codes

  • Taxonomy code: 363LF0000X , with the licence number:  2013015582 , registered in the state of MO ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 2008020336 . This is a "LICENSE" identifier , issued by the state of ( MO ) . This identifiers is of the category "OTHER".




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