Basic Information
| Provider Information | |||||||||
| NPI: | 1558326793 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | FEUTZ | ||||||||
| FirstName: | EDWARD | ||||||||
| MiddleName: | P | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1715 DEER TRACKS TRAIL | ||||||||
| Address2: | STE 130 | ||||||||
| City: | ST LOUIS | ||||||||
| State: | MO | ||||||||
| PostalCode: | 63131 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3148215600 | ||||||||
| FaxNumber: | 3148212180 | ||||||||
| Practice Location | |||||||||
| Address1: | 818 E BROADWAY | ||||||||
| Address2: | |||||||||
| City: | SPARTA | ||||||||
| State: | IL | ||||||||
| PostalCode: | 62288 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6184432177 | ||||||||
| FaxNumber: | 6184433035 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/19/2006 | ||||||||
| LastUpdateDate: | 07/20/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | IL | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 01720700481 | 05 | IL | MEDICAID | 141008 | 01 | HEALTHLINK | OTHER | 3654662 | 01 | IL | BLUE CROSS BLUE SHIELD | OTHER |