Organization
FAIRVIEW HEIGHTS MEDICAL GROUP, SC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
JOHN T ELLENA MD (MEDICAL DIRECTOR)
(314) 996-3434
Entity
Organization
Contact information
Practice address
670 MASON RIDGE CENTER DR, STE 300, SAINT LOUIS, MO 63141-8573
(314) 996-7644
(314) 996-7658
Mailing address
670 MASON RIDGE CENTER DR, SAINT LOUIS, MO 63141-8573
(314) 996-7644
(314) 996-7658
Taxonomy
Speciality
Code
Description
License number
State
207R00000X
Internal Medicine Physician
Primary
036.108281
IL
Other
Enumeration date
10/28/2014
Last updated
11/12/2014
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