Provider Demographics
NPI:1316245780
Name:DRX - FC MANAGEMENT 002, LLC
Entity type:Organization
Organization Name:DRX - FC MANAGEMENT 002, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:REGIONAL MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:BERNIE
Authorized Official - Middle Name:C
Authorized Official - Last Name:RANCHERO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:630-696-0714
Mailing Address - Street 1:1610 N KINGSHIGHWAY ST
Mailing Address - Street 2:THIRD FLOOR, SUITE 301
Mailing Address - City:CAPE GIRARDEAU
Mailing Address - State:MO
Mailing Address - Zip Code:63701-2196
Mailing Address - Country:US
Mailing Address - Phone:573-335-2900
Mailing Address - Fax:314-932-2417
Practice Address - Street 1:747 N NEW BALLAS RD
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63141-6715
Practice Address - Country:US
Practice Address - Phone:314-991-3030
Practice Address - Fax:314-991-3031
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-03-08
Last Update Date:2011-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO261QU0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QU0200XAmbulatory Health Care FacilitiesClinic/CenterUrgent Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOMA2870001Medicare UPIN
MOMA2870003Medicare UPIN
MOMA2870002Medicare UPIN