Basic Information
Provider Information | |||||||||
NPI: | 1932844495 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | SSM HEALTH CARE GROUP | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | SLUCARE PHYSICIAN GROUP | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 3545 LINDELL BLVD FL 3 | ||||||||
Address2: |   | ||||||||
City: | SAINT LOUIS | ||||||||
State: | MO | ||||||||
PostalCode: | 631031020 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6082804647 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 1225 S GRAND BLVD | ||||||||
Address2: | LEVEL 3 DOOR 3,4,5 | ||||||||
City: | SAINT LOUIS | ||||||||
State: | MO | ||||||||
PostalCode: | 631041016 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3149973400 | ||||||||
FaxNumber: | 3142563364 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 04/29/2022 | ||||||||
LastUpdateDate: | 08/25/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | LAMM | ||||||||
AuthorizedOfficialFirstName: | EILEEN | ||||||||
AuthorizedOfficialMiddleName: | M | ||||||||
AuthorizedOfficialTitleorPosition: | VICE PRESIDENT - FINANCE | ||||||||
AuthorizedOfficialTelephone: | 3149946219 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 08/25/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207ND0900X |   |   | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Dermatology | Dermatopathology |
No ID Information.