Provider Demographics
NPI:1093155905
Name:SSM DEPAUL HEALTH CENTER
Entity Type:Organization
Organization Name:SSM DEPAUL HEALTH CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT OF ACADEMIC AFFAIRS
Authorized Official - Prefix:DR
Authorized Official - First Name:JAY
Authorized Official - Middle Name:
Authorized Official - Last Name:MOORE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:314-334-6971
Mailing Address - Street 1:12303 DEPAUL DRIVE
Mailing Address - Street 2:
Mailing Address - City:BRIDGETON
Mailing Address - State:MO
Mailing Address - Zip Code:63044
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:12303 DE PAUL DR
Practice Address - Street 2:
Practice Address - City:BRIDGETON
Practice Address - State:MO
Practice Address - Zip Code:63044-2512
Practice Address - Country:US
Practice Address - Phone:314-334-6971
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-06-25
Last Update Date:2013-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes211D00000XPodiatric Medicine & Surgery Service ProvidersAssistant, PodiatricGroup - Single Specialty