1760550222 NPI number — MARION MEDICAL XRAY

Table of content: (NPI 1760550222)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1760550222 NPI number — MARION MEDICAL XRAY

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MARION MEDICAL XRAY
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:
MARION MEDICAL XRAY
Provider Other Organization Name Type Code:
5
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:
1760550222
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/19/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1008 W CHERRY ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MARION
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
62959-1998
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
618-997-6909
Provider Business Mailing Address Fax Number:
618-997-7759

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1008 W CHERRY ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MARION
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
62959-1998
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
618-997-6909
Provider Business Practice Location Address Fax Number:
618-997-7759
Provider Enumeration Date:
12/01/2006

Additional Information

Authorized Official

Authorized Official Last Name:
BRANDON
Authorized Official First Name:
JUDY
Authorized Official Middle Name:
KAY
Authorized Official Title or Position:
OFFICE MANAGER
Authorized Official Telephone Number:
618-997-6909

Provider Taxonomy Codes

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

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

  • Identifier: 693272 . This is a "MEDICARE GROUP PROVIDER #" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 164921 . This is a "FDA" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".
  • Identifier: 271836 . This is a "HEALTHLINK" identifier . This identifiers is of the category "OTHER".
  • Identifier: 1052274 . This is a "UMWA" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 2800075 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 863211 . This is a "DEPT OF LABOR" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 0360443201 , issued by the state of ( IL ) . This identifiers is of the category "MEDICAID".




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