MEDICARE: SSM REGIONAL HEALTH SERVCIES

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	261QU0200X	Urgent Care Clinic/Center

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1316993256
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SSM REGIONAL HEALTH SERVCIES

Provider Business Mailing Address
First Line	:	PO BOX 1027
Second Line	:
City	:	JEFFERSON CITY
State	:	MO
Zip	:	65102-1027
Country	:	US
Telephone Number	:	573-761-7246
Fax Number	:	573-761-6947

Provider Business Practice Location Address
First Line	:	2265 BAGNELL DAM BLVD
Second Line	:	STE 103
City	:	LAKE OZARK
State	:	MO
Zip	:	65049-8603
Country	:	US
Telephone Number	:	573-365-6800
Fax Number	:	573-365-6011

Authorized Official
Title or Position	:	PRESIDENT
Name	:	BRENT VAN CONIA
Credential	:
Telephone Number	:	573-761-7000

Provider Enumeration Date	:	05/25/2006
Last Update Date	:	10/28/2008

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