Basic Information
| Provider Information | |||||||||
| NPI: | 1457862708 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | BETTY JEAN KERR PEOPLES HEALTH CENTERS | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | PEOPLE'S HEALTHCARE SERVICES | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5701 DELMAR BLVD | ||||||||
| Address2: | |||||||||
| City: | SAINT LOUIS | ||||||||
| State: | MO | ||||||||
| PostalCode: | 631122617 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3143677848 | ||||||||
| FaxNumber: | 3143672985 | ||||||||
| Practice Location | |||||||||
| Address1: | 49 N FLORISSANT RD STE 101 | ||||||||
| Address2: | |||||||||
| City: | FERGUSON | ||||||||
| State: | MO | ||||||||
| PostalCode: | 631352312 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3146338921 | ||||||||
| FaxNumber: | 3145249227 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/13/2017 | ||||||||
| LastUpdateDate: | 11/26/2018 | ||||||||
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| AuthorizedOfficialLastName: | BUTLER | ||||||||
| AuthorizedOfficialFirstName: | DWAYNE | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRESIDENT & CEO | ||||||||
| AuthorizedOfficialTelephone: | 3143677848 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | BETTY JEAN KERR PEOPLES HEALTH CENTERS | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QF0400X | N00015533 | MO | Y | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
ID Information
| ID | Type | State | Issuer | Description | 500048820 | 05 | MO | MEDICAID |