Healthcare Provider Details

I. General information

NPI: 1760648802
Provider Name (Legal Business Name): MORGAN FAHEY-VORNBERG D.O.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/29/2008
Last Update Date: 11/18/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2900 FRANK SCOTT PKWY W #950
BELLEVILLE IL
62223-5000
US

IV. Provider business mailing address

2900 FRANK SCOTT PKWY W #950
BELLEVILLE IL
62223-5000
US

V. Phone/Fax

Practice location:
  • Phone: 618-233-3205
  • Fax: 618-233-1407
Mailing address:
  • Phone: 618-233-3205
  • Fax: 618-233-1407

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number125.054872
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: