Healthcare Provider Details

I. General information

NPI: 1093155905
Provider Name (Legal Business Name): SSM DEPAUL HEALTH CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/25/2013
Last Update Date: 06/25/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12303 DE PAUL DR
BRIDGETON MO
63044-2512
US

IV. Provider business mailing address

12303 DEPAUL DRIVE
BRIDGETON MO
63044
US

V. Phone/Fax

Practice location:
  • Phone: 314-334-6971
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code211D00000X
TaxonomyPodiatric Assistant
License Number
License Number State

VIII. Authorized Official

Name: DR. JAY MOORE
Title or Position: VICE PRESIDENT OF ACADEMIC AFFAIRS
Credential: MD
Phone: 314-334-6971