Provider Demographics
NPI:1811074651
Name:SSM CARDINAL GLENNON CHILDREN'S HOSPITAL
Entity type:Organization
Organization Name:SSM CARDINAL GLENNON CHILDREN'S HOSPITAL
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:EVP/COO
Authorized Official - Prefix:MS
Authorized Official - First Name:LYNN
Authorized Official - Middle Name:L
Authorized Official - Last Name:BOGGS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:314-768-8032
Mailing Address - Street 1:1465 S GRAND BLVD
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63104-1003
Mailing Address - Country:US
Mailing Address - Phone:314-577-5600
Mailing Address - Fax:
Practice Address - Street 1:12700 SOUTHFORK RD
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63128-3201
Practice Address - Country:US
Practice Address - Phone:314-543-5226
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SSM HEALTH CARE ST. LOUIS
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-11-01
Last Update Date:2011-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO167-1261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO507450302Medicaid
IL=========003Medicaid
MO507450302Medicaid