Provider Demographics
NPI:1275781288
Name:SSM MEDICAL GROUP
Entity Type:Organization
Organization Name:SSM MEDICAL GROUP
Other - Org Name:FAMILY PRACTICE OF SOUTH COUNTY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:E
Authorized Official - Last Name:BIESER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:314-822-5900
Mailing Address - Street 1:10777 SUNSET OFFICE DR
Mailing Address - Street 2:SUITE 310
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63127-1019
Mailing Address - Country:US
Mailing Address - Phone:314-822-5900
Mailing Address - Fax:314-822-5919
Practice Address - Street 1:1011 BOWLES AVE
Practice Address - Street 2:SUITE 300
Practice Address - City:FENTON
Practice Address - State:MO
Practice Address - Zip Code:63026-2387
Practice Address - Country:US
Practice Address - Phone:636-496-5000
Practice Address - Fax:636-496-5055
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-09-03
Last Update Date:2009-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOMA1247Medicare PIN