Provider Demographics
NPI:1952312951
Name:SSM DEPAUL MEDICAL GROUP, INC.
Entity Type:Organization
Organization Name:SSM DEPAUL MEDICAL GROUP, INC.
Other - Org Name:DEPAUL MEDICAL GROUP AT CROSS KEYS
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: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:63303-3541
Mailing Address - Country:US
Mailing Address - Phone:636-669-2268
Mailing Address - Fax:
Practice Address - Street 1:14021 NEW HALLS FERRY RD
Practice Address - Street 2:
Practice Address - City:FLORISSANT
Practice Address - State:MO
Practice Address - Zip Code:63033-2708
Practice Address - Country:US
Practice Address - Phone:314-839-0910
Practice Address - Fax:314-839-9053
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SSM DEPAUL MEDICAL GROUP
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-08-11
Last Update Date:2010-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
No213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO6438130003OtherMEDICARE DME
MO6438130003OtherMEDICARE DME