Healthcare Provider Details

I. General information

NPI: 1275781288
Provider Name (Legal Business Name): SSM MEDICAL GROUP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/03/2008
Last Update Date: 07/08/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1011 BOWLES AVE SUITE 300
FENTON MO
63026-2387
US

IV. Provider business mailing address

10777 SUNSET OFFICE DR SUITE 310
SAINT LOUIS MO
63127-1019
US

V. Phone/Fax

Practice location:
  • Phone: 636-496-5000
  • Fax: 636-496-5055
Mailing address:
  • Phone: 314-822-5900
  • Fax: 314-822-5919

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: JAMES E BIESER
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 314-822-5900