1497773063 NPI number — MARYVILLE RADIOLOGY GROUP, LTD

Table of content: (NPI 1497773063)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1497773063 NPI number — MARYVILLE RADIOLOGY GROUP, LTD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MARYVILLE RADIOLOGY GROUP, LTD
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1497773063
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/12/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 78130
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SAINT LOUIS
Provider Business Mailing Address State Name:
MO
Provider Business Mailing Address Postal Code:
63178-8130
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
309-363-4660
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
ILLINOIS ROUTE 162
Provider Second Line Business Practice Location Address:
ANDERSON HOSPITAL DEPT OF RADIOLOGY
Provider Business Practice Location Address City Name:
MARYVILLE
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
62062
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
618-288-5711
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
07/18/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
BURK
Authorized Official First Name:
TERRY
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
618-288-5711

Provider Taxonomy Codes

  • Taxonomy code: 2085R0202X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 149856 . This is a "BCBS" identifier , issued by the state of ( MO ) . This identifiers is of the category "OTHER".
  • Identifier: 6010052 . This is a "BCBS" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 99693 . This is a "GHP" identifier . This identifiers is of the category "OTHER".