Basic Information
| Provider Information | |||||||||
| NPI: | 1174962922 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SSM DEPAUL MEDICAL GROUP | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | SSM ORTHOPEDICS | ||||||||
| 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: | 12266 DEPAUL DRIVE | ||||||||
| Address2: | SUITE 110 | ||||||||
| City: | BRIDGETON | ||||||||
| State: | MO | ||||||||
| PostalCode: | 630442514 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3142917900 | ||||||||
| FaxNumber: | 3142917914 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/14/2013 | ||||||||
| LastUpdateDate: | 09/16/2015 | ||||||||
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| AuthorizedOfficialLastName: | PULLUM | ||||||||
| AuthorizedOfficialFirstName: | LAURA | ||||||||
| AuthorizedOfficialMiddleName: | L | ||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 6366692434 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207X00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | 332B00000X | Y | Suppliers | Durable Medical Equipment & Medical Supplies |
No ID Information.