Provider Demographics
NPI:1528421260
Name:SSM ST. CHARLES CLINIC MEDICAL GROUP, INC.
Entity type:Organization
Organization Name:SSM ST. CHARLES CLINIC MEDICAL GROUP, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:BILLING MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:LAURA
Authorized Official - Middle Name:
Authorized Official - Last Name:PULLUM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:636-699-2434
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:63303-3539
Mailing Address - Country:US
Mailing Address - Phone:636-669-2268
Mailing Address - Fax:
Practice Address - Street 1:1475 KISKER RD
Practice Address - Street 2:SUITE 200
Practice Address - City:SAINT CHARLES
Practice Address - State:MO
Practice Address - Zip Code:63304-8781
Practice Address - Country:US
Practice Address - Phone:636-498-5850
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-03-31
Last Update Date:2016-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies