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
1	207R00000X	Internal Medicine Physician
2	207V00000X	Obstetrics & Gynecology Physician
3	208000000X	Pediatrics Physician
4	208600000X	Surgery Physician
5	2086S0129X	Vascular Surgery Physician
6	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	:	1811932973
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	:	1551 WALL ST
Second Line	:	SUITE 400
City	:	SAINT CHARLES
State	:	MO
Zip	:	63303-3539
Country	:	US
Telephone Number	:	636-669-2350
Fax Number	:	636-669-2221

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

Provider Enumeration Date	:	06/20/2006
Last Update Date	:	01/15/2016

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Directions to “SSM ST. CHARLES CLINIC MEDICAL GROUP, INC. ” Practice Location

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