Healthcare Provider Details

I. General information

NPI: 1598823478
Provider Name (Legal Business Name): WEST COUNTY FAMILY MEDICINE, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/05/2006
Last Update Date: 05/05/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2355 DOUGHERTY FERRY RD STE 320
SAINT LOUIS MO
63122-3325
US

IV. Provider business mailing address

2355 DOUGHERTY FERRY RD STE 320
SAINT LOUIS MO
63122-3325
US

V. Phone/Fax

Practice location:
  • Phone: 314-821-6889
  • Fax: 314-821-1887
Mailing address:
  • Phone: 314-821-6889
  • Fax: 314-821-1887

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License NumberR8687
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number StateNULL

VIII. Authorized Official

Name: DR. DAVID NORMAN KANTOR
Title or Position: PRESIDENT, PHYSICIAN
Credential: D.O.
Phone: 314-821-6889