Healthcare Provider Details

I. General information

NPI: 1023297637
Provider Name (Legal Business Name): SSM MEDICAL GROUP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/31/2007
Last Update Date: 10/31/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4116 VON TALGE RD
SAINT LOUIS MO
63128-1957
US

IV. Provider business mailing address

4116 VON TALGE RD
SAINT LOUIS MO
63128-1957
US

V. Phone/Fax

Practice location:
  • Phone: 314-815-3331
  • Fax: 314-815-3703
Mailing address:
  • Phone: 314-815-3331
  • Fax: 314-815-3703

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State

VIII. Authorized Official

Name: LESA SCHNARR
Title or Position: DIRECTOR
Credential:
Phone: 314-951-5330