Provider Demographics
NPI:1457660896
Name:SSMDEPAUL MEDICAL GROUP
Entity Type:Organization
Organization Name:SSMDEPAUL MEDICAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTILAING COORDINATOR
Authorized Official - Prefix:
Authorized Official - First Name:BRIDGET
Authorized Official - Middle Name:
Authorized Official - Last Name:FRANCIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:636-669-2268
Mailing Address - Street 1:1551 WALL ST
Mailing Address - Street 2:SUITE 310
Mailing Address - City:SAINT CHARLES
Mailing Address - State:MO
Mailing Address - Zip Code:63303-3539
Mailing Address - Country:US
Mailing Address - Phone:636-669-2268
Mailing Address - Fax:314-209-8127
Practice Address - Street 1:1551 WALL ST
Practice Address - Street 2:SUITE 400
Practice Address - City:SAINT CHARLES
Practice Address - State:MO
Practice Address - Zip Code:63303-3539
Practice Address - Country:US
Practice Address - Phone:636-669-2350
Practice Address - Fax:636-669-2221
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SSM DEPAUL MEDICAL GROUP
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2010-10-04
Last Update Date:2010-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO207Q00000X, 213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO502915705Medicaid
MO000013572Medicare PIN