Healthcare Provider Details

I. General information

NPI: 1255664645
Provider Name (Legal Business Name): SSM CARDINAL GLENNON CHILDREN'S MEDICAL CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/16/2009
Last Update Date: 09/16/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1465 S GRAND BLVD
SAINT LOUIS MO
63104-1003
US

IV. Provider business mailing address

1465 S GRAND BLVD
SAINT LOUIS MO
63104-1003
US

V. Phone/Fax

Practice location:
  • Phone: 314-577-5600
  • Fax: 314-268-6441
Mailing address:
  • Phone: 314-577-5600
  • Fax: 314-268-6441

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code282NC2000X
TaxonomyChildren's Hospital
License Number363L00000X
License Number StateMO

VIII. Authorized Official

Name: M CHRISTINE GREEN
Title or Position: TRAUMA PROGRAM MANAGER
Credential: APRN
Phone: 314-577-5392