MEDICARE: SSM CARDINAL GLENNON CHILDRENS HOSPITAL

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	208000000X	Pediatrics Physician

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier Issuer
1	26D2159157	OTHER	CLIA
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1073568226
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SSM CARDINAL GLENNON CHILDRENS HOSPITAL

Provider Business Mailing Address
First Line	:	1173 CORPORATE LAKE DR
Second Line	:
City	:	SAINT LOUIS
State	:	MO
Zip	:	63132-1716
Country	:	US
Telephone Number	:	314-989-6843
Fax Number	:	314-344-7239

Provider Business Practice Location Address
First Line	:	2927 S . KINGS HIGHWAY BLVD
Second Line	:
City	:	SAINT LOUIS
State	:	MO
Zip	:	63139-1008
Country	:	US
Telephone Number	:	314-268-4070
Fax Number	:	314-268-4019

Authorized Official
Title or Position	:	SYSTEM VICE PRESIDENT FINANCE
Name	:	MRS. KAREN REWERTS
Credential	:	CFO
Telephone Number	:	314-989-6843

Provider Enumeration Date	:	05/24/2006
Last Update Date	:	11/18/2022

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Directions to “SSM CARDINAL GLENNON CHILDRENS HOSPITAL ” Practice Location

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