Provider Demographics
NPI:1811392210
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:MEDICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:T
Authorized Official - Last Name:ELLENA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:314-996-3434
Mailing Address - Street 1:670 MASON RIDGE CENTER DR
Mailing Address - Street 2:
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:STE 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:2014-10-28
Last Update Date:2014-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036.108281207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty