Basic Information
| Provider Information | |||||||||
| NPI: | 1275586174 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SSM HEALTH CARE ST LOUIS | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | SSM HEALTH ST. CLARE HOSPITAL PHYSICIAN BILLING | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1145 CORPORATE LAKE DR | ||||||||
| Address2: | |||||||||
| City: | SAINT LOUIS | ||||||||
| State: | MO | ||||||||
| PostalCode: | 631322907 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3149896843 | ||||||||
| FaxNumber: | 3143447281 | ||||||||
| Practice Location | |||||||||
| Address1: | 1015 BOWLES AVENUE | ||||||||
| Address2: | |||||||||
| City: | FENTON | ||||||||
| State: | MO | ||||||||
| PostalCode: | 63026 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6364962502 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/19/2006 | ||||||||
| LastUpdateDate: | 03/12/2019 | ||||||||
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| AuthorizedOfficialLastName: | DUDLEY | ||||||||
| AuthorizedOfficialFirstName: | SHARON | ||||||||
| AuthorizedOfficialMiddleName: | R. | ||||||||
| AuthorizedOfficialTitleorPosition: | EVP/COO | ||||||||
| AuthorizedOfficialTelephone: | 3147688032 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | SSM HEALTH CARE ST. LOUIS | ||||||||
| AuthorizedOfficialNamePrefix: | MS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2086S0129X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Surgery | Vascular Surgery | 207RC0000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease | 207P00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 545011009 | 05 | MO | MEDICAID |