MEDICARE: SSM CARDINAL GLENNON CHILDREN'S HOSPITAL

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	261QR1300X	Rural Health Clinic/Center
2	208000000X	Pediatrics Physician

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1962573212
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SSM CARDINAL GLENNON CHILDREN'S HOSPITAL

Provider Business Mailing Address
First Line	:	1195 CORPORATE LAKE DR
Second Line	:
City	:	SAINT LOUIS
State	:	MO
Zip	:	63132-1716
Country	:	US
Telephone Number	:	314-989-3524
Fax Number	:

Provider Business Practice Location Address
First Line	:	511 ASHLAND AVE
Second Line	:
City	:	WARRENTON
State	:	MO
Zip	:	63383-1065
Country	:	US
Telephone Number	:	636-456-0543
Fax Number	:

Authorized Official
Title or Position	:	REGIONAL CFO - FINANCIAL STRATEGY
Name	:	TIM BULLER
Credential	:
Telephone Number	:	314-989-2173

Provider Enumeration Date	:	11/10/2006
Last Update Date	:	07/19/2019

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