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Organization
FAIRVIEW HEIGHTS MEDICAL GROUP SC
Active
Organization
FAIRVIEW HEIGHTS MEDICAL GROUP SC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
DR. JOHN ELLENA M.D. (MEDICAL DIRECTOR)
(314) 434-8828
Entity
Organization
Contact information
Practice address
3165 MCKELVEY RD, 210, BRIDGETON, MO 63044-2550
(314) 996-8148
(314) 996-8134
Mailing address
11155 DUNN RD, 108N, SAINT LOUIS, MO 63136-6150
(314) 355-6779
(314) 355-4209
Taxonomy
Speciality
Code
Description
License number
State
261QM2500X
Medical Specialty Clinic/Center
Primary
—
NULL
Other
Enumeration date
12/29/2006
Last updated
08/22/2020
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