MEDICARE: SSM SELECT REHAB ST LOUIS LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103T00000X	Psychologist
2	208100000X	Physical Medicine & Rehabilitation Physician

General Provider Information

NPI Number	:	1558403261
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SSM SELECT REHAB ST LOUIS LLC

Provider Business Mailing Address
First Line	:	4714 GETTYSBURG RD
Second Line	:	ATTN LEGAL DEPARTMENT
City	:	MECHANICSBURG
State	:	PA
Zip	:	17055-4325
Country	:	US
Telephone Number	:	717-972-1100
Fax Number	:

Provider Business Practice Location Address
First Line	:	1027 BELLEVUE AVENUE
Second Line	:
City	:	RICHMOND HEIGHTS
State	:	MO
Zip	:	63117
Country	:	US
Telephone Number	:	314-768-8000
Fax Number	:

Authorized Official
Title or Position	:	VICE PRESIDENT
Name	:	MICHAEL E. TARVIN
Credential	:
Telephone Number	:	717-972-1100

Provider Enumeration Date	:	02/12/2007
Last Update Date	:	10/07/2011

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