Provider Demographics
NPI:1134285380
Name:FAIRVIEW HEIGHTS MEDICAL GROUP SC
Entity Type:Organization
Organization Name:FAIRVIEW HEIGHTS MEDICAL GROUP SC
Other - Org Name:FAMILY PHYSICIANS OF BETHALTO
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:RAYMOND
Authorized Official - Middle Name:P
Authorized Official - Last Name:DAVIDSON
Authorized Official - Suffix:II
Authorized Official - Credentials:MD
Authorized Official - Phone:314-286-2028
Mailing Address - Street 1:670 MASON RIDGE CENTER DR
Mailing Address - Street 2:SUITE 300
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63141-8573
Mailing Address - Country:US
Mailing Address - Phone:314-996-7644
Mailing Address - Fax:314-996-7658
Practice Address - Street 1:155 E BETHALTO DR
Practice Address - Street 2:
Practice Address - City:BETHALTO
Practice Address - State:IL
Practice Address - Zip Code:62010-1801
Practice Address - Country:US
Practice Address - Phone:618-377-8961
Practice Address - Fax:618-377-8962
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-29
Last Update Date:2008-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL413610Medicare ID - Type Unspecified