Basic Information
Provider Information
NPI: 1811392210
EntityType: 2
ReplacementNPI:  
OrganizationName: FAIRVIEW HEIGHTS MEDICAL GROUP, SC
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Mailing Information
Address1: 670 MASON RIDGE CENTER DR
Address2:  
City: SAINT LOUIS
State: MO
PostalCode: 631418573
CountryCode: US
TelephoneNumber: 3149967644
FaxNumber: 3149967658
Practice Location
Address1: 670 MASON RIDGE CENTER DR
Address2: STE 300
City: SAINT LOUIS
State: MO
PostalCode: 631418573
CountryCode: US
TelephoneNumber: 3149967644
FaxNumber: 3149967658
Other Information
ProviderEnumerationDate: 10/28/2014
LastUpdateDate: 11/12/2014
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AuthorizedOfficialLastName: ELLENA
AuthorizedOfficialFirstName: JOHN
AuthorizedOfficialMiddleName: T
AuthorizedOfficialTitleorPosition: MEDICAL DIRECTOR
AuthorizedOfficialTelephone: 3149963434
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IsOrganizationSubpart: N
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AuthorizedOfficialCredential: MD
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Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
207R00000X036.108281ILY193200000X MULTI-SPECIALTY GROUPAllopathic & Osteopathic PhysiciansInternal Medicine 

No ID Information.


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