Healthcare Provider Details

I. General information

NPI: 1063960409
Provider Name (Legal Business Name): SSM MEDICAL GROUP INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/14/2016
Last Update Date: 09/14/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

816 S KIRKWOOD RD SUITE 105
SAINT LOUIS MO
63122-6056
US

IV. Provider business mailing address

1551 WALL ST SUITE 310
SAINT CHARLES MO
63303-3539
US

V. Phone/Fax

Practice location:
  • Phone: 314-686-4990
  • Fax:
Mailing address:
  • Phone: 636-669-2268
  • Fax: 314-209-8127

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number
License Number StateMO

VIII. Authorized Official

Name: BARBARA PULLIAM
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 636-669-2455