Healthcare Provider Details

I. General information

NPI: 1285004598
Provider Name (Legal Business Name): SSM MEDICAL GROUP INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/29/2015
Last Update Date: 10/19/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12255 DEPAUL DRIVE SUITE 120
BRIDGETON MO
63044
US

IV. Provider business mailing address

3221 MCKELVEY RD STE 301
BRIDGETON MO
63044-2551
US

V. Phone/Fax

Practice location:
  • Phone: 314-291-7900
  • Fax:
Mailing address:
  • Phone: 636-498-5944
  • Fax: 314-209-8127

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208VP0000X
TaxonomyPain Medicine 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: BRIDGET EDER
Title or Position: PROVIDER ENROLLMENT SPECIALIST
Credential:
Phone: 636-498-5944