Provider Demographics
NPI:1538118492
Name:FOREST PARK HOSPITAL CORP #1
Entity Type:Organization
Organization Name:FOREST PARK HOSPITAL CORP #1
Other - Org Name:FAMILY MEDICINE OF ST LOUIS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:BUSINESS ADVISOR
Authorized Official - Prefix:MS
Authorized Official - First Name:JERRIE
Authorized Official - Middle Name:K
Authorized Official - Last Name:WEITH
Authorized Official - Suffix:
Authorized Official - Credentials:FHFMA
Authorized Official - Phone:618-779-5508
Mailing Address - Street 1:531 PEBBLE BROOK LN
Mailing Address - Street 2:HMAI
Mailing Address - City:BELLEVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62221-7609
Mailing Address - Country:US
Mailing Address - Phone:618-779-5508
Mailing Address - Fax:618-206-8588
Practice Address - Street 1:6125 CLAYTON AVE
Practice Address - Street 2:STE 222
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63139-3265
Practice Address - Country:US
Practice Address - Phone:314-768-3685
Practice Address - Fax:314-768-3940
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-09
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty