Provider Demographics
NPI:1659503217
Name:CLINICAL SUPPORT SERVICES, LLC
Entity Type:Organization
Organization Name:CLINICAL SUPPORT SERVICES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:NURSE PRACTITIONER
Authorized Official - Prefix:
Authorized Official - First Name:ELLEN
Authorized Official - Middle Name:M
Authorized Official - Last Name:MILLER
Authorized Official - Suffix:
Authorized Official - Credentials:NP
Authorized Official - Phone:618-558-3955
Mailing Address - Street 1:1501 LOCUST ST APT 906
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63103-1847
Mailing Address - Country:US
Mailing Address - Phone:618-558-3955
Mailing Address - Fax:
Practice Address - Street 1:1501 LOCUST ST APT 906
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63103-1847
Practice Address - Country:US
Practice Address - Phone:618-558-3955
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-08-17
Last Update Date:2009-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209001766363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOMA1983Medicare PIN
ILIL2548Medicare PIN