Provider Demographics
NPI:1275586174
Name:SSM HEALTH CARE ST LOUIS
Entity Type:Organization
Organization Name:SSM HEALTH CARE ST LOUIS
Other - Org Name:SSM HEALTH ST. CLARE HOSPITAL PHYSICIAN BILLING
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EVP/COO
Authorized Official - Prefix:MS
Authorized Official - First Name:SHARON
Authorized Official - Middle Name:R
Authorized Official - Last Name:DUDLEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:314-768-8032
Mailing Address - Street 1:1145 CORPORATE LAKE DR
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63132-2907
Mailing Address - Country:US
Mailing Address - Phone:314-989-6843
Mailing Address - Fax:314-344-7281
Practice Address - Street 1:1015 BOWLES AVENUE
Practice Address - Street 2:
Practice Address - City:FENTON
Practice Address - State:MO
Practice Address - Zip Code:63026
Practice Address - Country:US
Practice Address - Phone:636-496-2502
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SSM HEALTH CARE ST. LOUIS
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-05-19
Last Update Date:2019-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency MedicineGroup - Multi-Specialty
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Multi-Specialty
No2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular SurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO545011009Medicaid
MO000050113Medicare PIN