Provider Demographics
NPI:1306974233
Name:SSM HOME CARE PRIVATE DUTY
Entity type:Organization
Organization Name:SSM HOME CARE PRIVATE DUTY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:MIKE
Authorized Official - Middle Name:
Authorized Official - Last Name:TOPOLSKI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:314-989-2528
Mailing Address - Street 1:10143 PAGET DR
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63132-2915
Mailing Address - Country:US
Mailing Address - Phone:314-989-2524
Mailing Address - Fax:314-989-3901
Practice Address - Street 1:4385 MARYLAND AVE
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63108-2703
Practice Address - Country:US
Practice Address - Phone:314-533-4107
Practice Address - Fax:314-533-0058
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SSM HEALTH BUSINESSES
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-03-01
Last Update Date:2007-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NA251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO947658605Medicaid