MEDICARE: BETTY JEAN KERR PEOPLE'S HEALTH CENTERS

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	261QF0400X	Federally Qualified Health Center (FQHC)

General Provider Information

NPI Number	:	1780096941
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BETTY JEAN KERR PEOPLE'S HEALTH CENTERS

Provider Business Mailing Address
First Line	:	5701 DELMAR BLVD
Second Line	:
City	:	SAINT LOUIS
State	:	MO
Zip	:	63112-2617
Country	:	US
Telephone Number	:	314-367-7848
Fax Number	:	314-367-2985

Provider Business Practice Location Address
First Line	:	6701 SAINT CHARLES ROCK RD
Second Line	:
City	:	SAINT LOUIS
State	:	MO
Zip	:	63133-1705
Country	:	US
Telephone Number	:	314-367-7848
Fax Number	:	314-367-2985

Authorized Official
Title or Position	:	PRESIDENT & CEO
Name	:	DWAYNE BUTLER
Credential	:
Telephone Number	:	314-367-7848

Provider Enumeration Date	:	05/22/2014
Last Update Date	:	10/31/2014

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