Healthcare Provider Details

I. General information

NPI: 1639928690
Provider Name (Legal Business Name): SSM HEALTH CARE ST. LOUIS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/14/2024
Last Update Date: 05/19/2025
Certification Date: 05/19/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

301 CALEDONIA PKWY STE 110
O FALLON MO
63368-6690
US

IV. Provider business mailing address

301 CALEDONIA PKWY STE 110
O FALLON MO
63368-6690
US

V. Phone/Fax

Practice location:
  • Phone: 636-202-6810
  • Fax: 636-202-6811
Mailing address:
  • Phone: 636-202-6810
  • Fax: 636-202-6811

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: JEREMY FOTHERINGHAM
Title or Position: REGIONAL PRESIDENT
Credential:
Phone: 314-994-7930