Healthcare Provider Details

I. General information

NPI: 1447633557
Provider Name (Legal Business Name): SSM MEDICAL GROUP INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/07/2015
Last Update Date: 08/18/2020
Certification Date: 08/18/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 1ST CAPITOL DR SUITE 100
SAINT CHARLES MO
63301
US

IV. Provider business mailing address

PO BOX 955534
SAINT LOUIS MO
63195-5534
US

V. Phone/Fax

Practice location:
  • Phone: 636-332-8455
  • Fax:
Mailing address:
  • Phone: 636-498-5973
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207XX0005X
TaxonomySports Medicine (Orthopaedic Surgery) Physician
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State

VIII. Authorized Official

Name: KAREN REWERTS
Title or Position: VP FINANCIAL OPERATIONS
Credential:
Phone: 314-989-2034