Provider Demographics
NPI:1073568226
Name:SSM CARDINAL GLENNON CHILDRENS HOSPITAL
Entity Type:Organization
Organization Name:SSM CARDINAL GLENNON CHILDRENS HOSPITAL
Other - Org Name:SSM HEALTH CARDINAL GLENNON PEDIATRICS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SYSTEM VICE PRESIDENT FINANCE
Authorized Official - Prefix:MRS
Authorized Official - First Name:KAREN
Authorized Official - Middle Name:
Authorized Official - Last Name:REWERTS
Authorized Official - Suffix:
Authorized Official - Credentials:CFO
Authorized Official - Phone:314-989-6843
Mailing Address - Street 1:1173 CORPORATE LAKE DR
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63132-1716
Mailing Address - Country:US
Mailing Address - Phone:314-989-6843
Mailing Address - Fax:314-344-7239
Practice Address - Street 1:2927 S . KINGS HIGHWAY BLVD
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63139-1008
Practice Address - Country:US
Practice Address - Phone:314-268-4070
Practice Address - Fax:314-268-4019
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SSM CARDINAL GLENNON CHILDREN'S HOSPITAL
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-05-24
Last Update Date:2022-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
26D2159157OtherCLIA
MO505459107Medicaid
MO540155801Medicaid