Basic Information
| Provider Information | |||||||||
| NPI: | 1902281181 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SSM-SLUH INC | ||||||||
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| OtherOrganizationName: | SSM HEALTH SAINT LOUIS UNIVERSITY HOSPITAL | ||||||||
| 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: | 3149893695 | ||||||||
| Practice Location | |||||||||
| Address1: | 3635 VISTA AVE | ||||||||
| Address2: | |||||||||
| City: | SAINT LOUIS | ||||||||
| State: | MO | ||||||||
| PostalCode: | 631102539 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3145778000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/29/2015 | ||||||||
| LastUpdateDate: | 07/29/2015 | ||||||||
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| AuthorizedOfficialLastName: | BULLER | ||||||||
| AuthorizedOfficialFirstName: | TIMOTHY | ||||||||
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| AuthorizedOfficialTitleorPosition: | REGIONAL CFO - FINANCIAL STRATEGY | ||||||||
| AuthorizedOfficialTelephone: | 3149892173 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | SSM HEALTH CARE CORPORATION | ||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QE0700X | Y | Ambulatory Health Care Facilities | Clinic/Center | End-Stage Renal Disease (ESRD) Treatment |
No ID Information.