Healthcare Provider Details

I. General information

NPI: 1699002527
Provider Name (Legal Business Name): CARDINAL GLENNON CHILDREN'S HOSPITAL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/13/2009
Last Update Date: 11/13/2009
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: 314-577-5666
  • Fax:
Mailing address:
  • Phone: 314-577-5666
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code282NC2000X
TaxonomyChildren's Hospital
License NumberMO151383
License Number StateMO

VIII. Authorized Official

Name: MISS SHANNON LANEE MILLER
Title or Position: PEDIATRIC NURSE PRACTITIONER
Credential: RN, MSN, CPNP
Phone: 618-975-1607