Organization
SSM ST CHARLES CLINIC MEDICAL GROUP
Active
Organization subpart
No
Provider details
NPI number
Authorized official
LAURA PULLUM (DIRECTOR)
(636) 669-2434
Entity
Organization
Contact information
Practice address
400 MEDICAL PLZ, SUITE 200, LAKE ST LOUIS, MO 63367-1490
(636) 625-2662
(636) 625-1121
Mailing address
1551 WALL ST, SUITE 310, SAINT CHARLES, MO 63303-3539
(636) 669-2268
(314) 209-8127
Taxonomy
Speciality
Code
Description
License number
State
363LF0000X
Family Nurse Practitioner
Primary
2013015582
MO
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
2008020336
LICENSE
MO
Enumeration date
11/08/2013
Last updated
11/08/2013
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