1992860548 NPI number — MARION EYE CENTERS LTD

Table of content: (NPI 1992860548)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1992860548 NPI number — MARION EYE CENTERS LTD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MARION EYE CENTERS 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:
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:
1992860548
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/21/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1200 W DEYOUNG ST
Provider Second Line Business Mailing Address:
P.O. BOX 1178
Provider Business Mailing Address City Name:
MARION
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
62959-4437
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
618-993-5686
Provider Business Mailing Address Fax Number:
618-997-5505

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2900 BROADWAY ST
Provider Second Line Business Practice Location Address:
STE. A
Provider Business Practice Location Address City Name:
MOUNT VERNON
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
62864-2341
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
618-244-7777
Provider Business Practice Location Address Fax Number:
618-899-9022
Provider Enumeration Date:
12/26/2006

Additional Information

Authorized Official

Authorized Official Last Name:
AHMAD
Authorized Official First Name:
MAQBOOL
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT OWNER
Authorized Official Telephone Number:
618-993-5686

Provider Taxonomy Codes

  • Taxonomy code: 332B00000X , with the licence number:  036051996 , 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: 203169800 , issued by the state of ( MO ) . This identifiers is of the category "MEDICAID".
  • Identifier: 036051996 , issued by the state of ( IL ) . This identifiers is of the category "MEDICAID".




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