Healthcare Provider Details

I. General information

NPI: 1699087601
Provider Name (Legal Business Name): SSM CARDINAL GLENNON CHILDREN'S HOSPITAL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/07/2010
Last Update Date: 07/07/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1465 S GRAND BLVD DIET OFFICE
SAINT LOUIS MO
63104-1003
US

IV. Provider business mailing address

1465 S GRAND BLVD DIET OFFICE
SAINT LOUIS MO
63104-1003
US

V. Phone/Fax

Practice location:
  • Phone: 314-577-5319
  • Fax:
Mailing address:
  • Phone: 314-577-5319
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code282NC2000X
TaxonomyChildren's Hospital
License Number2010011211
License Number StateMO

VIII. Authorized Official

Name: ERICA L TIMMERMANN
Title or Position: REGISTERED DIETITIAN
Credential: MS, RD, LD
Phone: 314-577-5319