Basic Information
| Provider Information | |||||||||
| NPI: | 1306580659 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SSM HEALTH CARE GROUP | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | SLUCARE PHYSICIAN GROUP | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3545 LINDELL BLVD FL 3 | ||||||||
| Address2: | |||||||||
| City: | SAINT LOUIS | ||||||||
| State: | MO | ||||||||
| PostalCode: | 631031020 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6082804647 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1225 S GRAND BLVD | ||||||||
| Address2: | GL DOOR #1 | ||||||||
| City: | SAINT LOUIS | ||||||||
| State: | MO | ||||||||
| PostalCode: | 631041016 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3149773233 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/22/2022 | ||||||||
| LastUpdateDate: | 08/25/2022 | ||||||||
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| AuthorizedOfficialLastName: | LAMM | ||||||||
| AuthorizedOfficialFirstName: | EILEEN | ||||||||
| AuthorizedOfficialMiddleName: | M | ||||||||
| AuthorizedOfficialTitleorPosition: | VICE PRESIDENT- FINANCE | ||||||||
| AuthorizedOfficialTelephone: | 3149946219 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 08/25/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 156FC0800X | N | 193200000X MULTI-SPECIALTY GROUP | Eye and Vision Services Providers | Technician/Technologist | Contact Lens | 156FX1800X | N | 193200000X MULTI-SPECIALTY GROUP | Eye and Vision Services Providers | Technician/Technologist | Optician | 332H00000X | N | Suppliers | Eyewear Supplier (Equipment, not the service) | 332B00000X | Y | Suppliers | Durable Medical Equipment & Medical Supplies |
No ID Information.