1053664557 NPI number — SOUTHERN ILLINOIS SPINE & JOINT CENTER OF MARISSA LLC

Table of content: (NPI 1053664557)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1053664557 NPI number — SOUTHERN ILLINOIS SPINE & JOINT CENTER OF MARISSA LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SOUTHERN ILLINOIS SPINE & JOINT CENTER OF MARISSA LLC
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:
1053664557
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/12/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
112 N MAIN ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MARISSA
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
62257-1365
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
618-295-2268
Provider Business Mailing Address Fax Number:
618-295-3521

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
112 N MAIN ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MARISSA
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
62257-1365
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
618-295-2268
Provider Business Practice Location Address Fax Number:
618-295-3521
Provider Enumeration Date:
10/22/2012

Additional Information

Authorized Official

Authorized Official Last Name:
REISS
Authorized Official First Name:
RYAN
Authorized Official Middle Name:
Authorized Official Title or Position:
MANAGER
Authorized Official Telephone Number:
618-443-2026

Provider Taxonomy Codes

  • Taxonomy code: 111N00000X , with the licence number:  038011854 , 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)





Copyright © 2007-2025 www.npivalidator.com