Provider Demographics
NPI:1326336702
Name:DRX - FC MANAGEMENT 005, LLC
Entity Type:Organization
Organization Name:DRX - FC MANAGEMENT 005, LLC
Other - Org Name:DOCTORS EXPRESS - DES PERES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:REGIONAL MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:BERNIE
Authorized Official - Middle Name:C
Authorized Official - Last Name:RANCHERO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:630-696-0714
Mailing Address - Street 1:1610 N KINGSHIGHWAY ST
Mailing Address - Street 2:SUITE 301
Mailing Address - City:CAPE GIRARDEAU
Mailing Address - State:MO
Mailing Address - Zip Code:63701-2196
Mailing Address - Country:US
Mailing Address - Phone:573-335-2900
Mailing Address - Fax:314-932-2417
Practice Address - Street 1:11648 MANCHESTER RD
Practice Address - Street 2:
Practice Address - City:DES PERES
Practice Address - State:MO
Practice Address - Zip Code:63131-4612
Practice Address - Country:US
Practice Address - Phone:314-821-1099
Practice Address - Fax:314-395-0945
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-07-19
Last Update Date:2011-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QU0200XAmbulatory Health Care FacilitiesClinic/CenterUrgent Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOMA2870001Medicare UPIN
MOMA2870003Medicare UPIN
MOMA2870002Medicare UPIN