Healthcare Provider Details

I. General information

NPI: 1407912736
Provider Name (Legal Business Name): FAIRVIEW HEIGHTS MEDICAL GROUP SC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/29/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3165 MCKELVEY RD 210
BRIDGETON MO
63044-2550
US

IV. Provider business mailing address

11155 DUNN RD 108N
SAINT LOUIS MO
63136-6150
US

V. Phone/Fax

Practice location:
  • Phone: 314-996-8148
  • Fax: 314-996-8134
Mailing address:
  • Phone: 314-355-6779
  • Fax: 314-355-4209

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM2500X
TaxonomyMedical Specialty Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DR. JOHN ELLENA
Title or Position: MEDICAL DIRECTOR
Credential: M.D.
Phone: 314-434-8828