Provider Demographics
NPI:1053616110
Name:SSM MEDICAL GROUP INC.
Entity type:Organization
Organization Name:SSM MEDICAL GROUP INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:VP FINANCIAL OPERATIONS
Authorized Official - Prefix:
Authorized Official - First Name:KAREN
Authorized Official - Middle Name:
Authorized Official - Last Name:REWERTS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:314-989-2034
Mailing Address - Street 1:3221 MCKELVEY RD STE 301
Mailing Address - Street 2:
Mailing Address - City:BRIDGETON
Mailing Address - State:MO
Mailing Address - Zip Code:63044-2551
Mailing Address - Country:US
Mailing Address - Phone:636-498-5944
Mailing Address - Fax:314-209-8127
Practice Address - Street 1:12349 DE PAUL DR
Practice Address - Street 2:SUITE 100
Practice Address - City:BRIDGETON
Practice Address - State:MO
Practice Address - Zip Code:63044
Practice Address - Country:US
Practice Address - Phone:314-291-3399
Practice Address - Fax:314-291-3466
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SSM MEDICAL GROUP INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2011-01-21
Last Update Date:2020-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO207X00000X
332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO000013572Medicare PIN