Basic Information
| Provider Information | |||||||||
| NPI: | 1679503668 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | FAIRVIEW HEIGHTS MEDICAL GROUP SC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 670 MASON RIDGE CENTER DR | ||||||||
| Address2: | STE 300 | ||||||||
| City: | SAINT LOUIS | ||||||||
| State: | MO | ||||||||
| PostalCode: | 631418573 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3149967644 | ||||||||
| FaxNumber: | 3149967658 | ||||||||
| Practice Location | |||||||||
| Address1: | 670 MASON RIDGE CENTER DR | ||||||||
| Address2: | SUITE 300 | ||||||||
| City: | SAINT LOUIS | ||||||||
| State: | MO | ||||||||
| PostalCode: | 631418573 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3149967644 | ||||||||
| FaxNumber: | 3149967658 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/04/2006 | ||||||||
| LastUpdateDate: | 07/16/2020 | ||||||||
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| AuthorizedOfficialLastName: | CANTER-KOESTER | ||||||||
| AuthorizedOfficialFirstName: | KAREN | ||||||||
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| AuthorizedOfficialTitleorPosition: | VP OPERATIONS AND STRATEGY | ||||||||
| AuthorizedOfficialTelephone: | 3149967610 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 07/16/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM2500X | N | Ambulatory Health Care Facilities | Clinic/Center | Medical Specialty | 261QP2300X | N | Ambulatory Health Care Facilities | Clinic/Center | Primary Care | 261QM1300X | Y | Ambulatory Health Care Facilities | Clinic/Center | Multi-Specialty |
ID Information
| ID | Type | State | Issuer | Description | 500720107 | 05 | MO | MEDICAID |