Basic Information
| Provider Information | |||||||||
| NPI: | 1356412308 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SSM CARDINAL GLENNON CHILDREN'S HOSPITAL | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | SSM HEALTH CARDINAL GLENNON PEDIATRICS | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1195 CORPORATE LAKE DR | ||||||||
| Address2: | |||||||||
| City: | SAINT LOUIS | ||||||||
| State: | MO | ||||||||
| PostalCode: | 631321716 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3149893524 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 132 PROFESSIONAL PKWY | ||||||||
| Address2: | |||||||||
| City: | TROY | ||||||||
| State: | MO | ||||||||
| PostalCode: | 633792823 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6364625437 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/13/2006 | ||||||||
| LastUpdateDate: | 07/19/2019 | ||||||||
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| AuthorizedOfficialLastName: | BULLER | ||||||||
| AuthorizedOfficialFirstName: | TIM | ||||||||
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| AuthorizedOfficialTitleorPosition: | REGIONAL CFO - FINANCIAL STRATEGY | ||||||||
| AuthorizedOfficialTelephone: | 3149892173 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | SSM HEALTH CARE CORPORATION | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QR1300X | N | Ambulatory Health Care Facilities | Clinic/Center | Rural Health | 208000000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 505459107 | 05 | MO | MEDICAID |