Provider Demographics
NPI:1790851731
Name:PHYSICIAN GROUPS LC
Entity Type:Organization
Organization Name:PHYSICIAN GROUPS LC
Other - Org Name:UNION CLINIC
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 1:1780 OLD US HIGHWAY 50 E
Practice Address - Street 2:SUITE 102
Practice Address - City:UNION
Practice Address - State:MO
Practice Address - Zip Code:63084-3330
Practice Address - Country:US
Practice Address - Phone:636-583-8686
Practice Address - Fax:636-583-1765
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-28
Last Update Date:2008-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care