Basic Information
| Provider Information | |||||||||
| NPI: | 1851496152 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SSM HEALTH CARE ST. LOUIS | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | SSM HEALTH ST. CLARE HOSPITAL - FENTON | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1015 BOWLES AVE | ||||||||
| Address2: | |||||||||
| City: | FENTON | ||||||||
| State: | MO | ||||||||
| PostalCode: | 630262394 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6364962000 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1015 BOWLES AVE | ||||||||
| Address2: | |||||||||
| City: | FENTON | ||||||||
| State: | MO | ||||||||
| PostalCode: | 630262394 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6364962000 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/13/2006 | ||||||||
| LastUpdateDate: | 11/22/2019 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | GARRISON | ||||||||
| AuthorizedOfficialFirstName: | TINA | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 6364962502 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | SSM HEALTH CARE CORPORATION | ||||||||
| AuthorizedOfficialNamePrefix: | MS. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 282N00000X | 456-6 | MO | Y | Hospitals | General Acute Care Hospital |
ID Information
| ID | Type | State | Issuer | Description | 14878046 | 01 | MO | MISSOURI STATE TAX ID # | OTHER | 010417202 | 05 | MO | MEDICAID |