Provider Demographics
NPI:1639180631
Name:SSM DEPAUL MEDICAL GROUP, INC.
Entity Type:Organization
Organization Name:SSM DEPAUL MEDICAL GROUP, INC.
Other - Org Name:DEPAUL MEDICAL GROUP AT ST. CHARLES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR OF PATIENT ACCOUNTS
Authorized Official - Prefix:MS
Authorized Official - First Name:LAURA
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:PULLUM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:314-209-8121
Mailing Address - Street 1:1821 SHERMAN DR
Mailing Address - Street 2:
Mailing Address - City:SAINT CHARLES
Mailing Address - State:MO
Mailing Address - Zip Code:63303-3984
Mailing Address - Country:US
Mailing Address - Phone:636-949-8026
Mailing Address - Fax:636-949-5629
Practice Address - Street 1:1821 SHERMAN DR
Practice Address - Street 2:
Practice Address - City:SAINT CHARLES
Practice Address - State:MO
Practice Address - Zip Code:63303-3984
Practice Address - Country:US
Practice Address - Phone:636-949-8026
Practice Address - Fax:636-949-5629
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-11
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty