Provider Demographics
NPI:1427090836
Name:PHYSICIANS HEALTH GROUP, LLC
Entity type:Organization
Organization Name:PHYSICIANS HEALTH GROUP, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:
Authorized Official - Last Name:EDMISTON
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:636-305-2000
Mailing Address - Street 1:960 S HIGHWAY DR
Mailing Address - Street 2:
Mailing Address - City:FENTON
Mailing Address - State:MO
Mailing Address - Zip Code:63026-2023
Mailing Address - Country:US
Mailing Address - Phone:636-305-2000
Mailing Address - Fax:636-305-2000
Practice Address - Street 1:960 S HIGHWAY DR
Practice Address - Street 2:
Practice Address - City:FENTON
Practice Address - State:MO
Practice Address - Zip Code:63026-2023
Practice Address - Country:US
Practice Address - Phone:636-305-2000
Practice Address - Fax:636-305-2000
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-11
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO207RE0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & MetabolismGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO000013257Medicare ID - Type UnspecifiedGROUP ID