Basic Information
| Provider Information | |||||||||
| NPI: | 1851833305 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SSM HEALTHCARE | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1511 | ||||||||
| Address2: | |||||||||
| City: | LAKE SHERWOOD | ||||||||
| State: | MO | ||||||||
| PostalCode: | 633578511 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6363980110 | ||||||||
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| Practice Location | |||||||||
| Address1: | 500 MEDICAL DR | ||||||||
| Address2: | |||||||||
| City: | WENTZVILLE | ||||||||
| State: | MO | ||||||||
| PostalCode: | 633853421 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6363271000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/15/2016 | ||||||||
| LastUpdateDate: | 11/15/2016 | ||||||||
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| AuthorizedOfficialLastName: | GEERLING | ||||||||
| AuthorizedOfficialFirstName: | PAUL | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 6363271164 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| AuthorizedOfficialCredential: | LPC | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 283Q00000X | 003579 | MO | Y | Hospitals | Psychiatric Hospital |
No ID Information.