Healthcare Provider Details

I. General information

NPI: 1174962922
Provider Name (Legal Business Name): SSM DEPAUL MEDICAL GROUP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/14/2013
Last Update Date: 09/16/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12266 DEPAUL DRIVE SUITE 110
BRIDGETON MO
63044-2514
US

IV. Provider business mailing address

1551 WALL ST SUITE 310
SAINT CHARLES MO
63303-3539
US

V. Phone/Fax

Practice location:
  • Phone: 314-291-7900
  • Fax: 314-291-7914
Mailing address:
  • Phone: 636-669-2268
  • Fax: 314-209-8127

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State

VIII. Authorized Official

Name: LAURA L PULLUM
Title or Position: DIRECTOR
Credential:
Phone: 636-669-2434