Provider Demographics
NPI:1477564581
Name:SSM MEDICAL GROUP INC.
Entity Type:Organization
Organization Name:SSM MEDICAL GROUP INC.
Other - Org Name:SSM HEALTH MEDICAL GROUP
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VP FINANCIAL OPERATIONS
Authorized Official - Prefix:
Authorized Official - First Name:KAREN
Authorized Official - Middle Name:
Authorized Official - Last Name:REWERTS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:314-989-2034
Mailing Address - Street 1:3221 MCKELVEY RD STE 301
Mailing Address - Street 2:
Mailing Address - City:BRIDGETON
Mailing Address - State:MO
Mailing Address - Zip Code:63044-2551
Mailing Address - Country:US
Mailing Address - Phone:636-498-5944
Mailing Address - Fax:314-209-8127
Practice Address - Street 1:12255 DE PAUL DR
Practice Address - Street 2:SUITE 500
Practice Address - City:BRIDGETON
Practice Address - State:MO
Practice Address - Zip Code:63044
Practice Address - Country:US
Practice Address - Phone:314-209-5180
Practice Address - Fax:314-209-5153
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SSM MEDICAL GROUP INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-08-11
Last Update Date:2020-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
207Q00000X, 207R00000X, 207RE0101X, 207RP1001X, 332B00000X
MO213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & MetabolismGroup - Multi-Specialty
No207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary DiseaseGroup - Multi-Specialty
No213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO6438130004Medicare NSC