Basic Information
| Provider Information | |||||||||
| NPI: | 1073880480 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SSM DEPAUL MEDICAL GROUP, INC. | ||||||||
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| OtherOrganizationName: | SSM HEALTH MEDICAL GROUP | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1551 WALL ST | ||||||||
| Address2: | SUITE 310 | ||||||||
| City: | SAINT CHARLES | ||||||||
| State: | MO | ||||||||
| PostalCode: | 633033539 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6366692268 | ||||||||
| FaxNumber: | 3142098127 | ||||||||
| Practice Location | |||||||||
| Address1: | 2305 GEORGIA ST | ||||||||
| Address2: | |||||||||
| City: | LOUISIANA | ||||||||
| State: | MO | ||||||||
| PostalCode: | 633532559 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3142910846 | ||||||||
| FaxNumber: | 5737546056 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/30/2011 | ||||||||
| LastUpdateDate: | 01/15/2016 | ||||||||
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| AuthorizedOfficialLastName: | PULLUM | ||||||||
| AuthorizedOfficialFirstName: | LAURA | ||||||||
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| AuthorizedOfficialTitleorPosition: | BILLING MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 6366692434 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RC0000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease |
No ID Information.