Provider Demographics
NPI:1548578750
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:PROVIDER ENROLLMENT SPECIALIST
Authorized Official - Prefix:
Authorized Official - First Name:BRIDGET
Authorized Official - Middle Name:
Authorized Official - Last Name:EDER
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:63303-3541
Mailing Address - Country:US
Mailing Address - Phone:636-669-2268
Mailing Address - Fax:314-209-8129
Practice Address - Street 1:1101 HIGHWAY K
Practice Address - Street 2:
Practice Address - City:O FALLON
Practice Address - State:MO
Practice Address - Zip Code:63366
Practice Address - Country:US
Practice Address - Phone:636-379-6363
Practice Address - Fax:636-379-1297
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SSM MEDICAL GROUP INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2010-09-22
Last Update Date:2018-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO207Q00000X, 207R00000X, 207RR0500X, 207V00000X, 213E00000X
332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No207RR0500XAllopathic & Osteopathic PhysiciansInternal MedicineRheumatologyGroup - Multi-Specialty
No207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Multi-Specialty
No213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO501133607Medicaid
MO6452740001Medicare NSC
MO000010556Medicare PIN