MEDICARE: FOREST PARK HOSPITAL CORP #1

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician

General Provider Information

NPI Number	:	1538118492
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	FOREST PARK HOSPITAL CORP #1

Provider Business Mailing Address
First Line	:	531 PEBBLE BROOK LN
Second Line	:	HMAI
City	:	BELLEVILLE
State	:	IL
Zip	:	62221-7609
Country	:	US
Telephone Number	:	618-779-5508
Fax Number	:	618-206-8588

Provider Business Practice Location Address
First Line	:	6125 CLAYTON AVE
Second Line	:	STE 222
City	:	SAINT LOUIS
State	:	MO
Zip	:	63139-3265
Country	:	US
Telephone Number	:	314-768-3685
Fax Number	:	314-768-3940

Authorized Official
Title or Position	:	BUSINESS ADVISOR
Name	:	MS. JERRIE K WEITH
Credential	:	FHFMA
Telephone Number	:	618-779-5508

Provider Enumeration Date	:	05/09/2006
Last Update Date	:	08/22/2020

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