Provider Demographics
NPI:1144402660
Name:SSM MEDICAL GROUP
Entity Type:Organization
Organization Name:SSM MEDICAL GROUP
Other - Org Name:MID COUNTY INTERNAL MEDICINE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:LESA
Authorized Official - Middle Name:
Authorized Official - Last Name:SCHNARR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:314-951-5330
Mailing Address - Street 1:7980 CLAYTON RD
Mailing Address - Street 2:SUITE 202
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63117-1354
Mailing Address - Country:US
Mailing Address - Phone:314-951-5368
Mailing Address - Fax:
Practice Address - Street 1:1031 BELLEVUE AVE
Practice Address - Street 2:SUITE 300
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63117-1818
Practice Address - Country:US
Practice Address - Phone:314-644-0042
Practice Address - Fax:314-644-1507
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-27
Last Update Date:2008-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOCG1303OtherRAILROAD MEDICARE