Basic Information
| Provider Information | |||||||||
| NPI: | 1326109885 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | FOREST CITY FAMILY PRACTICE LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1000 N JEFFERSON ST | ||||||||
| Address2: | |||||||||
| City: | SAINT JAMES | ||||||||
| State: | MO | ||||||||
| PostalCode: | 655591078 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5732658840 | ||||||||
| FaxNumber: | 5732658884 | ||||||||
| Practice Location | |||||||||
| Address1: | 1000 N JEFFERSON ST | ||||||||
| Address2: | |||||||||
| City: | SAINT JAMES | ||||||||
| State: | MO | ||||||||
| PostalCode: | 655591078 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5732658840 | ||||||||
| FaxNumber: | 5732658884 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/12/2006 | ||||||||
| LastUpdateDate: | 12/08/2009 | ||||||||
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| AuthorizedOfficialLastName: | SCHUETZ | ||||||||
| AuthorizedOfficialFirstName: | HUGH | ||||||||
| AuthorizedOfficialMiddleName: | A | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 5732658840 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| AuthorizedOfficialCredential: | DO | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 596841403 | 05 | MO | MEDICAID |