Healthcare Provider Details

I. General information

NPI: 1366400855
Provider Name (Legal Business Name): SSM HEALTH CARE ST. LOUIS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/03/2006
Last Update Date: 10/09/2020
Certification Date: 10/09/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6420 CLAYTON RD
SAINT LOUIS MO
63117-1811
US

IV. Provider business mailing address

1145 CORPORATE LAKE DR
SAINT LOUIS MO
63132-2907
US

V. Phone/Fax

Practice location:
  • Phone: 314-768-8000
  • Fax:
Mailing address:
  • Phone: 314-989-6189
  • Fax: 314-344-7281

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code207RP1001X
TaxonomyPulmonary Disease Physician
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code207ZC0500X
TaxonomyCytopathology Physician
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code207U00000X
TaxonomyNuclear Medicine Physician
License Number
License Number State
# 7
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: MS. SHARON R. DUDLEY
Title or Position: EVP/COO
Credential:
Phone: 314-768-8032