Basic Information
| Provider Information | |||||||||
| NPI: | 1548578750 | ||||||||
| 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: | 1551 WALL ST | ||||||||
| Address2: | SUITE 310 | ||||||||
| City: | SAINT CHARLES | ||||||||
| State: | MO | ||||||||
| PostalCode: | 633033541 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6366692268 | ||||||||
| FaxNumber: | 3142098129 | ||||||||
| Practice Location | |||||||||
| Address1: | 1101 HIGHWAY K | ||||||||
| Address2: | |||||||||
| City: | O FALLON | ||||||||
| State: | MO | ||||||||
| PostalCode: | 63366 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6363796363 | ||||||||
| FaxNumber: | 6363791297 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/22/2010 | ||||||||
| LastUpdateDate: | 07/16/2018 | ||||||||
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| AuthorizedOfficialLastName: | EDER | ||||||||
| AuthorizedOfficialFirstName: | BRIDGET | ||||||||
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| AuthorizedOfficialTitleorPosition: | PROVIDER ENROLLMENT SPECIALIST | ||||||||
| AuthorizedOfficialTelephone: | 6366692268 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | SSM MEDICAL GROUP INC. | ||||||||
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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 | 207R00000X | MO | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | 207RR0500X | MO | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Rheumatology | 207V00000X | MO | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | 213E00000X | MO | N | 193200000X MULTI-SPECIALTY GROUP | Podiatric Medicine & Surgery Service Providers | Podiatrist | 332B00000X | Y | Suppliers | Durable Medical Equipment & Medical Supplies |
ID Information
| ID | Type | State | Issuer | Description | 501133607 | 05 | MO | MEDICAID |