1770530727 NPI number — VILLAGE OF MARYVILLE

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 1770530727 NPI number — VILLAGE OF MARYVILLE

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
VILLAGE OF MARYVILLE
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:
6
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:
1770530727
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/19/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 457
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WHEELING
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60090-0457
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
847-577-8811
Provider Business Mailing Address Fax Number:
847-577-7967

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2520 N CENTER ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MARYVILLE
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
62062-5671
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
618-344-8099
Provider Business Practice Location Address Fax Number:
618-344-2990
Provider Enumeration Date:
05/27/2006

Additional Information

Authorized Official

Authorized Official Last Name:
FLAUGHER
Authorized Official First Name:
KEVIN
Authorized Official Middle Name:
Authorized Official Title or Position:
FIRE CHIEF
Authorized Official Telephone Number:
618-344-8099

Provider Taxonomy Codes

  • Taxonomy code: 3416L0300X , with the licence number:  4 4868 , 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: 6032131 . This is a "BCBS" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 216357500 . This is a "DOL OWCP" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 590007562 . This is a "PALMETTO RR MEDICARE" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".




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