Provider Demographics
NPI:1073022000
Name:FAIRVIEW HEIGHTS MEDICAL GROUP SC
Entity type:Organization
Organization Name:FAIRVIEW HEIGHTS MEDICAL GROUP SC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:T
Authorized Official - Last Name:ELLENA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:314-996-7644
Mailing Address - Street 1:660 MASON RIDGE CENTER DR STE 300
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63141-8512
Mailing Address - Country:US
Mailing Address - Phone:314-996-7663
Mailing Address - Fax:314-996-7658
Practice Address - Street 1:660 MASON RIDGE CENTER DR STE 300
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63141-8512
Practice Address - Country:US
Practice Address - Phone:314-996-7644
Practice Address - Fax:314-996-7658
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-09-21
Last Update Date:2025-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty
No261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty
No261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care