Basic Information
| Provider Information | |||||||||
| NPI: | 1073568226 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SSM CARDINAL GLENNON CHILDRENS HOSPITAL | ||||||||
| LastName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | SSM HEALTH CARDINAL GLENNON PEDIATRICS | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1145 CORPORATE LAKE DRIVE | ||||||||
| Address2: | |||||||||
| City: | SAINT LOUIS | ||||||||
| State: | MO | ||||||||
| PostalCode: | 631322907 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3149896843 | ||||||||
| FaxNumber: | 3143447281 | ||||||||
| Practice Location | |||||||||
| Address1: | 4100 FOREST PARK AVE STE 101A | ||||||||
| Address2: | |||||||||
| City: | SAINT LOUIS | ||||||||
| State: | MO | ||||||||
| PostalCode: | 631082885 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3145775627 | ||||||||
| FaxNumber: | 3143447281 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/24/2006 | ||||||||
| LastUpdateDate: | 03/21/2019 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | REWERTS | ||||||||
| AuthorizedOfficialFirstName: | KAREN | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | SYSTEM VICE PRESIDENT FINANCE | ||||||||
| AuthorizedOfficialTelephone: | 3149896843 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | SSM CARDINAL GLENNON CHILDREN'S HOSPITAL | ||||||||
| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | CFO | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 540155801 | 05 | MO | MEDICAID | 26D2159157 | 01 | CLIA | OTHER | 505459107 | 05 | MO | MEDICAID |