Provider Demographics
NPI:1962573212
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:REGIONAL CFO - FINANCIAL STRATEGY
Authorized Official - Prefix:
Authorized Official - First Name:TIM
Authorized Official - Middle Name:
Authorized Official - Last Name:BULLER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:314-989-2173
Mailing Address - Street 1:1195 CORPORATE LAKE DR
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63132-1716
Mailing Address - Country:US
Mailing Address - Phone:314-989-3524
Mailing Address - Fax:
Practice Address - Street 1:511 ASHLAND AVE
Practice Address - Street 2:
Practice Address - City:WARRENTON
Practice Address - State:MO
Practice Address - Zip Code:63383-1065
Practice Address - Country:US
Practice Address - Phone:636-456-0543
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SSM HEALTH CARE ST. LOUIS
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-11-10
Last Update Date:2019-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
No261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO599262300Medicaid