Healthcare Provider Details

I. General information

NPI: 1891123477
Provider Name (Legal Business Name): SSM DEPAUL MEDICAL GROUP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/17/2013
Last Update Date: 10/17/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1551 WALL ST SUITE 400
SAINT CHARLES MO
63303-3539
US

IV. Provider business mailing address

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

V. Phone/Fax

Practice location:
  • Phone: 636-669-2420
  • Fax: 636-669-2401
Mailing address:
  • Phone: 636-669-2268
  • Fax: 314-209-8127

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207QA0505X
TaxonomyAdult Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code213E00000X
TaxonomyPodiatrist
License Number2004019662
License Number StateMO

VIII. Authorized Official

Name: LAURA PULLUM
Title or Position: DIRECTOR
Credential:
Phone: 636-669-2434