Basic Information
| Provider Information | |||||||||
| NPI: | 1285004598 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SSM MEDICAL GROUP INC. | ||||||||
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| OtherOrganizationName: | SSM HEALTH MEDICAL GROUP | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3221 MCKELVEY RD STE 301 | ||||||||
| Address2: | |||||||||
| City: | BRIDGETON | ||||||||
| State: | MO | ||||||||
| PostalCode: | 630442551 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6364985944 | ||||||||
| FaxNumber: | 3142098127 | ||||||||
| Practice Location | |||||||||
| Address1: | 12255 DEPAUL DRIVE | ||||||||
| Address2: | SUITE 120 | ||||||||
| City: | BRIDGETON | ||||||||
| State: | MO | ||||||||
| PostalCode: | 63044 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3142917900 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/29/2015 | ||||||||
| LastUpdateDate: | 10/19/2018 | ||||||||
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| AuthorizedOfficialLastName: | EDER | ||||||||
| AuthorizedOfficialFirstName: | BRIDGET | ||||||||
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| AuthorizedOfficialTitleorPosition: | PROVIDER ENROLLMENT SPECIALIST | ||||||||
| AuthorizedOfficialTelephone: | 6364985944 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208VP0000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pain Medicine | Pain Medicine | 332B00000X | Y | Suppliers | Durable Medical Equipment & Medical Supplies |
No ID Information.