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Organization Active NPI

SSM Cardinal Glennon Childrens Hospital

Doing business as SSM Health Cardinal Glennon Children's Hospital

  • Pediatrics Physician
  • O'Fallon, IL
National Provider Identifier
1174577670
Registry record updated Sep 30, 2020
On this page

Key facts

NPPES NPI Registry
Primary specialty
Pediatrics PhysicianTaxonomy code 208000000X
Legal business name
SSM CARDINAL GLENNON CHILDRENS HOSPITAL
Doing business as
SSM Health Cardinal Glennon Children's Hospital
Practice address
1 Saint Elizabeth Blvd
O Fallon, IL 62269-1099
Phone
(618) 234-2120
NPI assigned
May 19, 2006
Last updated
Sep 30, 2020By the provider in NPPES
Organization subpart
Yes
Parent organization
SSM CARDINAL GLENNON CHILDRENS HOSPITALAs reported in NPPES

NPPES NPI Registry

Updated by the provider on Sep 30, 2020

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Karen Rewerts
Title
VP Finance
Phone
(314) 989-2034

Specialties & licenses 7

Specialty (taxonomy)CodeLicenseStatePrimary
Psychologist 103T00000X NU
Social Worker 104100000X NU
Cytopathology Physician 207ZC0500X NU
Pediatrics Physician 208000000X NU Primary
Psychiatry Physician 2084P0800X NU
Body Imaging Physician 2085B0100X NU
Pediatric Obesity Medicine Physician 2080B0002X NU

Addresses

Primary practice location

1 Saint Elizabeth Blvd
O Fallon, IL 62269-1099

Mailing address

1145 Corporate Lake Dr
Saint Louis, MO 63132-2907
Phone (314) 989-6843

Other practice location 1

13000 Butler Crest Dr
Saint Louis, MO 63128-4276
Phone (314) 842-3535

Other practice location 2

226 S Woods Mill Rd Ste 62W
Chesterfield, MO 63017-3665
Phone (314) 469-3990

Other practice location 3

1465 S Grand Blvd
Saint Louis, MO 63104-1003
Phone (314) 577-5600

Other identifiers 1

IdentifierTypeStateIssuer
540155801MedicaidMO

Other names 1

  • SSM Health Cardinal Glennon Children's Hospital Doing business as

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in MO, IL2 enrollments

Enrollment records 2

Enrollment IDStateProvider typePAC IDDetails
O20031231000604 MO Part B Supplier - Clinic/Group Practice 7012828163 Receives reassigned benefits from 436 practitioners
1 other NPI on this enrollment
Practice locations: Saint Louis, MO; Bridgeton, MO; Chesterfield, MO; Florissant, MO; Lake St Louis, MO
O20170612002061 IL Part B Supplier - Clinic/Group Practice 7012828163 Receives reassigned benefits from 78 practitioners
1 other NPI on this enrollment
This NPI is an additional NPI on the enrollment
Practice locations: Edwardsville, IL; Granite City, IL; Maryville, IL; O Fallon, IL

Other NPIs with the same Medicare PAC ID 3

NPIs whose Medicare enrollments share a PECOS associate control ID (the same enrolled entity).

Other NPIs on the same Medicare enrollment 1

NPIs listed together on one Medicare enrollment, typically parts of the same organization.

National Provider Directory

National Provider Directory
Part of
SSM Cardinal Glennon Childrens Hospital

Member of 1

Organizations this organization is a member of, according to the National Provider Directory.

Locations

3403 Anderson Healthcare Dr
#B
Edwardsville, IL 62025
Phone (618) 288-5606

12255 De Paul Dr
Ste 300
Bridgeton, MO 63044
Phone (314) 209-0933

Ownership & related parties

All facility ownership & control disclosures 2

Facilities whose Medicare enrollment lists this provider’s PECOS associate ID as an owner or managing party.

FacilityTypeRoleSince
SSM Health Carninal Glennon PediatricsTroy, MO, CCN 263906 Rural health clinic 5% Or Greater Direct Ownership Interest (100%) Sep 1, 2015
SSM Helath Cardinal Glennon PediatricsWarrenton, MO, CCN 263974 Rural health clinic 5% Or Greater Direct Ownership Interest (100%) Sep 1, 2015

Owned or controlled facilities with NPI records 2

Facilities whose Medicare enrollment lists this provider as an owner, officer, director or managing party.

Practitioners & affiliated clinicians

Practitioners 492

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

View all 492

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1147996800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1601424000000",
    "number": "1174577670",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1145 CORPORATE LAKE DR",
            "city": "SAINT LOUIS",
            "state": "MO",
            "postal_code": "631322907",
            "telephone_number": "314-989-6843",
            "fax_number": "314-989-7281"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1 SAINT ELIZABETH BLVD",
            "city": "O FALLON",
            "state": "IL",
            "postal_code": "622691099",
            "telephone_number": "618-234-2120"
        }
    ],
    "practiceLocations": [
        {
            "address_1": "13000 Butler Crest Dr",
            "address_purpose": "LOCATION",
            "city": "Saint Louis",
            "state": "MO",
            "postal_code": "631284276",
            "country_code": "US",
            "telephone_number": "314-842-3535",
            "fax_number": "314-344-7281",
            "country_name": "United States",
            "address_type": "DOM"
        },
        {
            "address_1": "226 S Woods Mill Rd Ste 62W",
            "address_purpose": "LOCATION",
            "city": "Chesterfield",
            "state": "MO",
            "postal_code": "630173665",
            "country_code": "US",
            "telephone_number": "314-469-3990",
            "fax_number": "314-344-7281",
            "country_name": "United States",
            "address_type": "DOM"
        },
        {
            "address_1": "1465 S Grand Blvd",
            "address_purpose": "LOCATION",
            "city": "Saint Louis",
            "state": "MO",
            "postal_code": "631041003",
            "country_code": "US",
            "telephone_number": "314-577-5600",
            "fax_number": "314-268-6468",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "basic": {
        "organization_name": "SSM CARDINAL GLENNON CHILDRENS HOSPITAL",
        "organizational_subpart": "YES",
        "parent_organization_legal_business_name": "SSM CARDINAL GLENNON CHILDRENS HOSPITAL",
        "enumeration_date": "2006-05-19",
        "last_updated": "2020-09-30",
        "certification_date": "2020-08-24",
        "status": "A",
        "authorized_official_last_name": "REWERTS",
        "authorized_official_first_name": "KAREN",
        "authorized_official_title_or_position": "VP FINANCE",
        "authorized_official_telephone_number": "314-989-2034"
    },
    "taxonomies": [
        {
            "code": "103T00000X",
            "taxonomy_group": "",
            "desc": "Psychologist",
            "state": "NU",
            "license": null,
            "primary": false
        },
        {
            "code": "104100000X",
            "taxonomy_group": "",
            "desc": "Social Worker",
            "state": "NU",
            "license": null,
            "primary": false
        },
        {
            "code": "207ZC0500X",
            "taxonomy_group": "",
            "desc": "Pathology, Cytopathology",
            "state": "NU",
            "license": null,
            "primary": false
        },
        {
            "code": "208000000X",
            "taxonomy_group": "",
            "desc": "Pediatrics",
            "state": "NU",
            "license": null,
            "primary": true
        },
        {
            "code": "2084P0800X",
            "taxonomy_group": "",
            "desc": "Psychiatry & Neurology, Psychiatry",
            "state": "NU",
            "license": null,
            "primary": false
        },
        {
            "code": "2085B0100X",
            "taxonomy_group": "",
            "desc": "Radiology, Body Imaging",
            "state": "NU",
            "license": null,
            "primary": false
        },
        {
            "code": "2080B0002X",
            "taxonomy_group": "",
            "desc": "Pediatrics, Obesity Medicine",
            "state": "NU",
            "license": null,
            "primary": false
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "540155801",
            "state": "MO"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "SSM Health Cardinal Glennon Children's Hospital",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in O'Fallon, IL

Sources for this page

Verify at the official NPI Registry.