Healthcare Provider Details

I. General information

NPI: 1174577670
Provider Name (Legal Business Name): SSM CARDINAL GLENNON CHILDRENS HOSPITAL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/19/2006
Last Update Date: 09/30/2020
Certification Date: 08/24/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 SAINT ELIZABETH BLVD
O FALLON IL
62269-1099
US

IV. Provider business mailing address

1145 CORPORATE LAKE DR
SAINT LOUIS MO
63132-2907
US

V. Phone/Fax

Practice location:
  • Phone: 618-234-2120
  • Fax:
Mailing address:
  • Phone: 314-989-6843
  • Fax: 314-989-7281

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2085B0100X
TaxonomyBody Imaging Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code207ZC0500X
TaxonomyCytopathology Physician
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code2080B0002X
TaxonomyPediatric Obesity Medicine Physician
License Number
License Number State
# 7
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State

VIII. Authorized Official

Name: KAREN REWERTS
Title or Position: VP FINANCE
Credential:
Phone: 314-989-2034