Healthcare Provider Details

I. General information

NPI: 1700966207
Provider Name (Legal Business Name): SSM MEDICAL GROUP, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/17/2006
Last Update Date: 08/18/2020
Certification Date: 08/18/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1011 BOWLES AVE SUITE 300
FENTON MO
63026-2395
US

IV. Provider business mailing address

PO BOX 955534
SAINT LOUIS MO
63195-5534
US

V. Phone/Fax

Practice location:
  • Phone: 636-496-5000
  • Fax: 636-496-5045
Mailing address:
  • Phone: 636-498-5944
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number
License Number State

VIII. Authorized Official

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