Provider Demographics
NPI:1558326793
Name:FEUTZ, EDWARD P (MD)
Entity Type:Individual
Prefix:
First Name:EDWARD
Middle Name:P
Last Name:FEUTZ
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1715 DEER TRACKS TRAIL
Mailing Address - Street 2:STE 130
Mailing Address - City:ST LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63131
Mailing Address - Country:US
Mailing Address - Phone:314-821-5600
Mailing Address - Fax:314-821-2180
Practice Address - Street 1:818 E BROADWAY
Practice Address - Street 2:
Practice Address - City:SPARTA
Practice Address - State:IL
Practice Address - Zip Code:62288
Practice Address - Country:US
Practice Address - Phone:618-443-2177
Practice Address - Fax:618-443-3035
Is Sole Proprietor?:No
Enumeration Date:2006-04-19
Last Update Date:2007-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL2085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL01720700481Medicaid
141008OtherHEALTHLINK
IL3654662OtherBLUE CROSS BLUE SHIELD
IL3654662OtherBLUE CROSS BLUE SHIELD
ILL13880Medicare ID - Type Unspecified