Basic Information
Provider Information | |||||||||
NPI: | 1619097763 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | FRITZ | ||||||||
FirstName: | JOSEPH | ||||||||
MiddleName: | MICHAEL | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 224 S WOODS MILL RD STE 510S | ||||||||
Address2: |   | ||||||||
City: | CHESTERFIELD | ||||||||
State: | MO | ||||||||
PostalCode: | 630173611 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3142056605 | ||||||||
FaxNumber: | 3145905928 | ||||||||
Practice Location | |||||||||
Address1: | 224 S WOODS MILL RD | ||||||||
Address2: | STE 620 | ||||||||
City: | CHESTERFIELD | ||||||||
State: | MO | ||||||||
PostalCode: | 630173451 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3142056605 | ||||||||
FaxNumber: | 3145905928 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 03/30/2007 | ||||||||
LastUpdateDate: | 12/07/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 12/07/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 2008006168 | MO | N |   | Allopathic & Osteopathic Physicians | Internal Medicine |   | 207RI0200X | 2008006168 | MO | Y |   | Allopathic & Osteopathic Physicians | Internal Medicine | Infectious Disease |
ID Information
ID | Type | State | Issuer | Description | 2008006168 | 01 | MO | MEDICAL LICENSE | OTHER |