Healthcare Provider Details

I. General information

NPI: 1093858276
Provider Name (Legal Business Name): FAIRVIEW HEIGHTS MEDICAL GROUP SC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/15/2007
Last Update Date: 01/07/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 MEMORIAL DR SUITE G204
ALTON IL
62002-6722
US

IV. Provider business mailing address

670 MASON RIDGE CENTER DR SUITE 300
SAINT LOUIS MO
63141-8573
US

V. Phone/Fax

Practice location:
  • Phone: 618-465-7887
  • Fax:
Mailing address:
  • Phone: 314-996-7644
  • Fax: 314-996-7658

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: RAYMOND P DAVIDSON II
Title or Position: PRESIDENT
Credential: MD
Phone: 314-286-2028