Provider Demographics
NPI:1578670949
Name:SSM ST. CHARLES CLINIC MEDICAL GROUP, INC.
Entity Type:Organization
Organization Name:SSM ST. CHARLES CLINIC MEDICAL GROUP, INC.
Other - Org Name:SSM HEALTH MEDICAL GROUP
Other - Org Type:Doing Business As
Authorized Official - Title/Position:BILLING MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:LAURA
Authorized Official - Middle Name:
Authorized Official - Last Name:PULLUM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:636-669-2434
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 1:722 N HIGHWAY 47
Practice Address - Street 2:SUITE B
Practice Address - City:WARRENTON
Practice Address - State:MO
Practice Address - Zip Code:63383-1108
Practice Address - Country:US
Practice Address - Phone:636-456-3413
Practice Address - Fax:636-669-2401
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-23
Last Update Date:2016-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO501133649Medicaid
MO501133649Medicaid