Basic Information
| Provider Information | |||||||||
| NPI: | 1285741629 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SSM ST. CHARLES CLINIC 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: | 172 PROFESSIONAL PARKWAY | ||||||||
| Address2: | |||||||||
| City: | TROY | ||||||||
| State: | MO | ||||||||
| PostalCode: | 633791520 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6364626106 | ||||||||
| FaxNumber: | 6366692401 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/23/2006 | ||||||||
| 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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| AuthorizedOfficialNamePrefix: | MS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | 207RC0000X | R9286 | MO | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease | 207R00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 501887806 | 05 | MO | MEDICAID |