| Organization Name: | SSM ST CHARLES CLINIC MEDICAL GROUP |
| NPI Number: | 1518396670 |
| Entity Type Code: | Organizational (2) |
| Authorized Official Name: | LAURA PULLUM (DIRECTOR) |
| Mailing Address: | 400 Medical Plz Suite 200 Lake St Louis |
| State: | MO US |
| Postal Code: | 633671490 |
| Phone Number: | 6366252662 |
| Fax Number: | 6366251121 |
| NPI Enumeration Date: | 11/08/2013 |
| NPI Last Update Date: | 11/08/2013 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 363LF0000X |
| License Number: | 2013015582 |
| Healthcare Provider Taxonomy: (Secondary) | Y |
| State: | MO |
| Taxonomy Type: | Physician Assistants & Advanced Practice Nursing Providers |
| Taxonomy Classification: | Nurse Practitioner |
| Taxonomy Specialization: | Family |
| Taxonomy Definition: | |