NPIMap

Organization Active NPI

Fairview Heights Medical Group SC

  • Medical Specialty Clinic/Center
  • Bridgeton, MO
National Provider Identifier
1407912736
Registry record updated Aug 22, 2020
On this page

Key facts

NPPES NPI Registry
Primary specialty
Medical Specialty Clinic/CenterTaxonomy code 261QM2500X
Legal business name
FAIRVIEW HEIGHTS MEDICAL GROUP SC
Practice address
3165 McKelvey Rd
210
Bridgeton, MO 63044-2550
Phone
(314) 996-8148
Fax
(314) 996-8134
NPI assigned
Dec 29, 2006
Last updated
Aug 22, 2020By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Aug 22, 2020

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Dr. John Ellena, M.D.
Title
Medical Director
Phone
(314) 434-8828

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Medical Specialty Clinic/Center 261QM2500X NU Primary

Addresses

Primary practice location

3165 McKelvey Rd
210
Bridgeton, MO 63044-2550

Mailing address

11155 Dunn Rd
108N
Saint Louis, MO 63136-6150
Phone (314) 355-6779

National Provider Directory

National Provider Directory
Tax ID family
Fairview Heights Medica23 organizations share this tax ID, including this one

Other organizations with this tax ID 22

Organizations that report the same tax identification number in the National Provider Directory.

View all 22

Locations

3165 McKelvey Rd
Ste 210
Bridgeton, MO 63044
Phone (314) 996-8105

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1167350400000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1598054400000",
    "number": "1407912736",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "11155 DUNN RD",
            "address_2": "108N",
            "city": "SAINT LOUIS",
            "state": "MO",
            "postal_code": "631366150",
            "telephone_number": "314-355-6779",
            "fax_number": "314-355-4209"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "3165 MCKELVEY RD",
            "address_2": "210",
            "city": "BRIDGETON",
            "state": "MO",
            "postal_code": "630442550",
            "telephone_number": "314-996-8148",
            "fax_number": "314-996-8134"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "FAIRVIEW HEIGHTS MEDICAL GROUP SC",
        "organizational_subpart": "NO",
        "enumeration_date": "2006-12-29",
        "last_updated": "2020-08-22",
        "status": "A",
        "authorized_official_last_name": "ELLENA",
        "authorized_official_first_name": "JOHN",
        "authorized_official_title_or_position": "MEDICAL DIRECTOR",
        "authorized_official_telephone_number": "314-434-8828",
        "authorized_official_name_prefix": "Dr.",
        "authorized_official_credential": "M.D."
    },
    "taxonomies": [
        {
            "code": "261QM2500X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Medical Specialty",
            "state": "NU",
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

Other providers in Bridgeton, MO

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Aug 22, 2020; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.