Provider Demographics
NPI:1679503668
Name:FAIRVIEW HEIGHTS MEDICAL GROUP SC
Entity Type:Organization
Organization Name:FAIRVIEW HEIGHTS MEDICAL GROUP SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VP OPERATIONS AND STRATEGY
Authorized Official - Prefix:
Authorized Official - First Name:KAREN
Authorized Official - Middle Name:
Authorized Official - Last Name:CANTER-KOESTER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:314-996-7610
Mailing Address - Street 1:670 MASON RIDGE CENTER DR
Mailing Address - Street 2:STE 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 1:670 MASON RIDGE CENTER DR
Practice Address - Street 2:SUITE 300
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63141-8573
Practice Address - Country:US
Practice Address - Phone:314-996-7644
Practice Address - Fax:314-996-7658
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-04
Last Update Date:2020-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty
No261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty
No261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO500720107Medicaid
MO500720107Medicaid
MO000014884Medicare ID - Type Unspecified