Healthcare Provider Details

I. General information

NPI: 1962573212
Provider Name (Legal Business Name): SSM CARDINAL GLENNON CHILDREN'S HOSPITAL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/10/2006
Last Update Date: 07/19/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

511 ASHLAND AVE
WARRENTON MO
63383-1065
US

IV. Provider business mailing address

1195 CORPORATE LAKE DR
SAINT LOUIS MO
63132-1716
US

V. Phone/Fax

Practice location:
  • Phone: 636-456-0543
  • Fax:
Mailing address:
  • Phone: 314-989-3524
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QR1300X
TaxonomyRural Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: TIM BULLER
Title or Position: REGIONAL CFO - FINANCIAL STRATEGY
Credential:
Phone: 314-989-2173