Basic Information
| Provider Information | |||||||||
| NPI: | 1457660896 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SSMDEPAUL MEDICAL GROUP | ||||||||
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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: | 1551 WALL ST | ||||||||
| Address2: | SUITE 400 | ||||||||
| City: | SAINT CHARLES | ||||||||
| State: | MO | ||||||||
| PostalCode: | 633033539 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6366692350 | ||||||||
| FaxNumber: | 6366692221 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/04/2010 | ||||||||
| LastUpdateDate: | 10/04/2010 | ||||||||
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| AuthorizedOfficialLastName: | FRANCIS | ||||||||
| AuthorizedOfficialFirstName: | BRIDGET | ||||||||
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| AuthorizedOfficialTitleorPosition: | CREDENTILAING COORDINATOR | ||||||||
| AuthorizedOfficialTelephone: | 6366692268 | ||||||||
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| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | SSM DEPAUL MEDICAL GROUP | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | MO | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | 213ES0103X | MO | Y | 193200000X MULTI-SPECIALTY GROUP | Podiatric Medicine & Surgery Service Providers | Podiatrist | Foot & Ankle Surgery |
ID Information
| ID | Type | State | Issuer | Description | 502915705 | 05 | MO | MEDICAID |