Provider Demographics
NPI:1598823478
Name:WEST COUNTY FAMILY MEDICINE, INC
Entity type:Organization
Organization Name:WEST COUNTY FAMILY MEDICINE, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT, PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:NORMAN
Authorized Official - Last Name:KANTOR
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:314-821-6889
Mailing Address - Street 1:2355 DOUGHERTY FERRY RD
Mailing Address - Street 2:STE 320
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63122-3325
Mailing Address - Country:US
Mailing Address - Phone:314-821-6889
Mailing Address - Fax:314-821-1887
Practice Address - Street 1:2355 DOUGHERTY FERRY RD
Practice Address - Street 2:STE 320
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63122-3325
Practice Address - Country:US
Practice Address - Phone:314-821-6889
Practice Address - Fax:314-821-1887
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-05
Last Update Date:2008-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
207Q00000X
MOR8687261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO240189704Medicaid
MO000015645Medicare PIN