Provider Demographics
NPI:1053664557
Name:SOUTHERN ILLINOIS SPINE & JOINT CENTER OF MARISSA LLC
Entity Type:Organization
Organization Name:SOUTHERN ILLINOIS SPINE & JOINT CENTER OF MARISSA LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:DR
Authorized Official - First Name:RYAN
Authorized Official - Middle Name:
Authorized Official - Last Name:REISS
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:618-443-2026
Mailing Address - Street 1:112 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:MARISSA
Mailing Address - State:IL
Mailing Address - Zip Code:62257-1365
Mailing Address - Country:US
Mailing Address - Phone:618-295-2268
Mailing Address - Fax:618-295-3521
Practice Address - Street 1:112 N MAIN ST
Practice Address - Street 2:
Practice Address - City:MARISSA
Practice Address - State:IL
Practice Address - Zip Code:62257-1365
Practice Address - Country:US
Practice Address - Phone:618-295-2268
Practice Address - Fax:618-295-3521
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-10-22
Last Update Date:2012-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL038011854111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty