Provider Demographics
NPI:1255664645
Name:SSM CARDINAL GLENNON CHILDREN'S MEDICAL CENTER
Entity Type:Organization
Organization Name:SSM CARDINAL GLENNON CHILDREN'S MEDICAL CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:TRAUMA PROGRAM MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:M
Authorized Official - Middle Name:CHRISTINE
Authorized Official - Last Name:GREEN
Authorized Official - Suffix:
Authorized Official - Credentials:APRN
Authorized Official - Phone:314-577-5392
Mailing Address - Street 1:1465 S GRAND BLVD
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63104-1003
Mailing Address - Country:US
Mailing Address - Phone:314-577-5600
Mailing Address - Fax:314-268-6441
Practice Address - Street 1:1465 S GRAND BLVD
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63104-1003
Practice Address - Country:US
Practice Address - Phone:314-577-5600
Practice Address - Fax:314-268-6441
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SSM HEALTHCARE
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2009-09-16
Last Update Date:2009-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO363L00000X282NC2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282NC2000XHospitalsGeneral Acute Care HospitalChildren
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO079924OtherSTATE APRN LICENSE