NPIMap

Organization Active NPI

Fairview Heights Medical Group, SC

  • Internal Medicine Physician
  • Saint Louis, MO
National Provider Identifier
1811392210
Registry record updated Nov 12, 2014
On this page

Key facts

NPPES NPI Registry
Primary specialty
Internal Medicine PhysicianTaxonomy code 207R00000X
License
036.108281 Issued in IL
Legal business name
FAIRVIEW HEIGHTS MEDICAL GROUP, SC
Practice address
670 Mason Ridge Center Dr
Ste 300
Saint Louis, MO 63141-8573
Phone
(314) 996-7644
Fax
(314) 996-7658
NPI assigned
Oct 28, 2014
Last updated
Nov 12, 2014By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Nov 12, 2014

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

Authorized official

Name
John T Ellena, MD
Title
Medical Director
Phone
(314) 996-3434

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Internal Medicine Physician 207R00000X 036.108281 IL Primary

Addresses

Primary practice location

670 Mason Ridge Center Dr
Ste 300
Saint Louis, MO 63141-8573

Mailing address

670 Mason Ridge Center Dr
Saint Louis, MO 63141-8573
Phone (314) 996-7644

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in IL

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20040309000650 IL Part B Supplier - Clinic/Group Practice 6800784083 Receives reassigned benefits from 526 practitioners
2 other NPIs on this enrollment
This NPI is an additional NPI on the enrollment
Practice locations: Shiloh, IL; Bethalto, IL; Collinsville, IL; Columbia, IL; Edwardsville, IL; Godfrey, IL; Maryville, IL; O Fallon, IL…

Other NPIs on the same Medicare enrollment 2

NPIs listed together on one Medicare enrollment, typically parts of the same organization.

National Provider Directory

National Provider Directory

NPI Registry JSON

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

{
    "created_epoch": "1414454400000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1415750400000",
    "number": "1811392210",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "670 MASON RIDGE CENTER DR",
            "city": "SAINT LOUIS",
            "state": "MO",
            "postal_code": "631418573",
            "telephone_number": "314-996-7644",
            "fax_number": "314-996-7658"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "670 MASON RIDGE CENTER DR",
            "address_2": "STE 300",
            "city": "SAINT LOUIS",
            "state": "MO",
            "postal_code": "631418573",
            "telephone_number": "314-996-7644",
            "fax_number": "314-996-7658"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "FAIRVIEW HEIGHTS MEDICAL GROUP, SC",
        "organizational_subpart": "NO",
        "enumeration_date": "2014-10-28",
        "last_updated": "2014-11-12",
        "status": "A",
        "authorized_official_last_name": "ELLENA",
        "authorized_official_first_name": "JOHN",
        "authorized_official_middle_name": "T",
        "authorized_official_title_or_position": "MEDICAL DIRECTOR",
        "authorized_official_telephone_number": "314-996-3434",
        "authorized_official_credential": "MD"
    },
    "taxonomies": [
        {
            "code": "207R00000X",
            "taxonomy_group": "",
            "desc": "Internal Medicine",
            "state": "IL",
            "license": "036.108281",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

Other providers in Saint Louis, MO

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Nov 12, 2014; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.