Provider Demographics
NPI:1174577670
Name:SSM CARDINAL GLENNON CHILDRENS HOSPITAL
Entity type:Organization
Organization Name:SSM CARDINAL GLENNON CHILDRENS HOSPITAL
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:VP FINANCE
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 1:1145 CORPORATE LAKE DR
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63132-2907
Mailing Address - Country:US
Mailing Address - Phone:314-989-6843
Mailing Address - Fax:314-989-7281
Practice Address - Street 1:1 SAINT ELIZABETH BLVD
Practice Address - Street 2:
Practice Address - City:O FALLON
Practice Address - State:IL
Practice Address - Zip Code:62269-1099
Practice Address - Country:US
Practice Address - Phone:618-234-2120
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SSM CARDINAL GLENNON CHILDRENS HOSPITAL
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-05-19
Last Update Date:2020-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
No2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Multi-Specialty
No2085B0100XAllopathic & Osteopathic PhysiciansRadiologyBody ImagingGroup - Multi-Specialty
No103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Multi-Specialty
No104100000XBehavioral Health & Social Service ProvidersSocial WorkerGroup - Multi-Specialty
No207ZC0500XAllopathic & Osteopathic PhysiciansPathologyCytopathologyGroup - Multi-Specialty
No2080B0002XAllopathic & Osteopathic PhysiciansPediatricsObesity MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO540155801Medicaid
MO540155801Medicaid