Healthcare Provider Details

I. General information

NPI: 1881605905
Provider Name (Legal Business Name): SSM DEPAUL MEDICAL GROUP, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/11/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9068 OVERLAND PLZ
OVERLAND MO
63114-6122
US

IV. Provider business mailing address

9068 OVERLAND PLZ
OVERLAND MO
63114-6122
US

V. Phone/Fax

Practice location:
  • Phone: 314-423-9000
  • Fax: 314-423-7035
Mailing address:
  • Phone: 314-423-9000
  • Fax: 314-423-7035

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: MS. LAURA LYNN PULLUM
Title or Position: DIRECTOR OF PATIENT ACCOUNTS
Credential:
Phone: 314-209-8121