Provider Demographics
NPI:1518006956
Name:ST. JOSEPH'S HEALTH CENTER WOMEN'S AND CHILDREN'S SERVICES CLINIC
Entity Type:Organization
Organization Name:ST. JOSEPH'S HEALTH CENTER WOMEN'S AND CHILDREN'S SERVICES CLINIC
Other - Org Name:PHYSICIANS OF SSM ST. LOUIS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:NETWORK VICE PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:DIANNE
Authorized Official - Middle Name:P
Authorized Official - Last Name:BARRY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:314-989-2180
Mailing Address - Street 1:1836 LACKLAND HILL PKWY
Mailing Address - Street 2:ATTN CREDENTIALING DEPT
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63146-3572
Mailing Address - Country:US
Mailing Address - Phone:314-989-0300
Mailing Address - Fax:
Practice Address - Street 1:600 MEDICAL DR
Practice Address - Street 2:SUITE 209
Practice Address - City:WENTZVILLE
Practice Address - State:MO
Practice Address - Zip Code:63385-3426
Practice Address - Country:US
Practice Address - Phone:636-332-8482
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-05
Last Update Date:2007-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2006023270207RC0200X, 207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary DiseaseGroup - Multi-Specialty
No207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOH40618Medicare UPIN