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Organization Active NPI

SSM Cardinal Glennon Children's Hospital

Doing business as SSM Health Cardinal Glennon Pediatrics

  • Pediatrics Physician
  • Troy, MO
National Provider Identifier
1356412308
Registry record updated Jul 19, 2019
On this page

Key facts

NPPES NPI Registry
Primary specialty
Pediatrics PhysicianTaxonomy code 208000000X
Legal business name
SSM CARDINAL GLENNON CHILDREN'S HOSPITAL
Doing business as
SSM Health Cardinal Glennon Pediatrics
Practice address
132 Professional Pkwy
Troy, MO 63379-2823
Phone
(636) 462-5437
NPI assigned
Nov 13, 2006
Last updated
Jul 19, 2019By the provider in NPPES
Organization subpart
Yes
Parent organization
SSM HEALTH CARE CORPORATIONAs reported in NPPES

NPPES NPI Registry

Updated by the provider on Jul 19, 2019

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

Authorized official

Name
Tim Buller
Title
Regional Cfo - Financial Strategy
Phone
(314) 989-2173

Specialties & licenses 2

Specialty (taxonomy)CodeLicenseStatePrimary
Rural Health Clinic/Center 261QR1300X NU
Pediatrics Physician 208000000X NU Primary

Addresses

Primary practice location

132 Professional Pkwy
Troy, MO 63379-2823

Mailing address

1195 Corporate Lake Dr
Saint Louis, MO 63132-1716
Phone (314) 989-3524

Other identifiers 1

IdentifierTypeStateIssuer
505459107MedicaidMO

Other names 1

  • SSM Health Cardinal Glennon Pediatrics Doing business as

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in MO

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20200121000961 MO Part A Provider - Rural Health Clinic 7012828163 Practice locations: Troy, MO

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1356412308. Details of each certification follow.

Rural health clinic certification: CCN 263906

Legal name
SSM CARDINAL GLENNON CHILDREN'S HOSPITAL
Doing business as
SSM HEALTH CARNINAL GLENNON PEDIATRICS
Certification status
Active
Provider type (POS)
Rural health clinic
Participating since
Apr 30, 2001
Last certification
Apr 25, 2023
Ownership / control type
2B
Organization structure
CorporationNon-profit
Incorporated
Dec 22, 1999 in MO
Enrollment address
132 Professional Pkwy
Troy, MO 63379-2823

Other NPIs with the same Medicare PAC ID 3

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

National Provider Directory

National Provider Directory
Tax ID family
SSM Cardinal Glennon Childrens Hospital7 organizations share this tax ID, including this one
Part of
SSM Health Care Corporation

Other organizations with this tax ID 6

Organizations that report the same tax identification number in the National Provider Directory.

Member of 1

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

Locations

1195 Corporate Lake Dr
Saint Louis, MO 63132

132 Professional Pkwy
Troy, MO 63379
Phone (636) 462-5437

Ownership & related parties

All disclosed owners & managing parties 7

As disclosed on the Medicare enrollment (CMS All Owners files). Individuals include officers, directors and managing employees, who may not hold ownership.

NameRoleSinceShare
Karen D Rewerts Individual Corporate OfficerSystem Vice President May 3, 2010
Douglas P Long Individual Corporate OfficerGeneral Counsel SSM Helathcare Jun 1, 2019
SSM Health Care Corporation Organization, Saint Louis, MO Corporation, Non-profit 5% Or Greater Indirect Ownership Interest Sep 1, 2015 85%
SSM Cardinal Glennon Children's Hospital Organization, Saint Louis, MO Corporation, Non-profit 5% Or Greater Direct Ownership Interest Sep 1, 2015 100%
St Louis University Organization, Saint Louis, MO Corporation, Non-profit 5% Or Greater Indirect Ownership Interest Sep 1, 2015 15%
Timothy Buller Individual Corporate DirectorRegional Cfo Financial Strategy Oct 30, 2014
Operational/Managerial ControlRegional Cfo Financial Strategy Oct 9, 2013
Laura Kaiser Individual Corporate Officer May 1, 2017

Owners & managing parties with NPI records 3

Owners and managing parties disclosed on this facility’s Medicare enrollment that are themselves Medicare-enrolled.

All facility ownership & control disclosures 1

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

FacilityTypeRoleSince
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 1

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

Facilities with the same owner 30

Facilities that share an organizational owner with 5% or greater ownership or operational control.

View all 30

Parent organization (reported in NPPES) 1

This organization reports itself as a subpart in NPPES; the parent’s legal name matches this organization in the same state.

NPI Registry JSON

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

{
    "created_epoch": "1163376000000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1563494400000",
    "number": "1356412308",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1195 CORPORATE LAKE DR",
            "city": "SAINT LOUIS",
            "state": "MO",
            "postal_code": "631321716",
            "telephone_number": "314-989-3524"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "132 PROFESSIONAL PKWY",
            "city": "TROY",
            "state": "MO",
            "postal_code": "633792823",
            "telephone_number": "636-462-5437"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "SSM CARDINAL GLENNON CHILDREN'S HOSPITAL",
        "organizational_subpart": "YES",
        "parent_organization_legal_business_name": "SSM HEALTH CARE CORPORATION",
        "enumeration_date": "2006-11-13",
        "last_updated": "2019-07-19",
        "status": "A",
        "authorized_official_last_name": "BULLER",
        "authorized_official_first_name": "TIM",
        "authorized_official_title_or_position": "REGIONAL CFO - FINANCIAL STRATEGY",
        "authorized_official_telephone_number": "314-989-2173"
    },
    "taxonomies": [
        {
            "code": "261QR1300X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Rural Health",
            "state": "NU",
            "license": null,
            "primary": false
        },
        {
            "code": "208000000X",
            "taxonomy_group": "",
            "desc": "Pediatrics",
            "state": "NU",
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "505459107",
            "state": "MO"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "SSM Health Cardinal Glennon Pediatrics",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Troy, MO

Sources for this page

Verify at the official NPI Registry.