1467409599 NPI number — MARIO J MARCINCZYK MD

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1467409599 NPI number — MARIO J MARCINCZYK MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MARCINCZYK
Provider First Name:
MARIO
Provider Middle Name:
J
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

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:
1467409599
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/09/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 1125
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MARYLAND HEIGHTS
Provider Business Mailing Address State Name:
MO
Provider Business Mailing Address Postal Code:
63043-0125
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
888-731-1036
Provider Business Mailing Address Fax Number:
423-892-5838

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1 MEMORIAL DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ALTON
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
62002-6722
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
618-463-7311
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
05/26/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207L00000X , with the licence number:  2005024595 , registered in the state of MO ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207L00000X , with the licence number: 036.095452 , 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: 036095452 , issued by the state of ( IL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 203133 . This is a "BCBS" identifier , issued by the state of ( MO ) . This identifiers is of the category "OTHER".
  • Identifier: 207562307 , issued by the state of ( MO ) . This identifiers is of the category "MEDICAID".
  • Identifier: P00316808 . This is a "RR MEDICARE" identifier . This identifiers is of the category "OTHER".




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