MEDICARE: SSM ST. CHARLES CLINIC MEDICAL GROUP, INC.

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	207Q00000X	Family Medicine Physician

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	:	1578670949
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SSM ST. CHARLES CLINIC MEDICAL GROUP, INC.

Provider Business Mailing Address
First Line	:	1551 WALL ST
Second Line	:	SUITE 310
City	:	SAINT CHARLES
State	:	MO
Zip	:	63303-3539
Country	:	US
Telephone Number	:	636-669-2268
Fax Number	:	314-209-8127

Provider Business Practice Location Address
First Line	:	722 N HIGHWAY 47
Second Line	:	SUITE B
City	:	WARRENTON
State	:	MO
Zip	:	63383-1108
Country	:	US
Telephone Number	:	636-456-3413
Fax Number	:	636-669-2401

Authorized Official
Title or Position	:	BILLING MANAGER
Name	:	MS. LAURA PULLUM
Credential	:
Telephone Number	:	636-669-2434

Provider Enumeration Date	:	08/23/2006
Last Update Date	:	01/15/2016

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