Provider Demographics
NPI:1073628129
Name:MEINERS, MARSHA L (PA-C)
Entity Type:Individual
Prefix:
First Name:MARSHA
Middle Name:L
Last Name:MEINERS
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:MARSHA
Other - Middle Name:L
Other - Last Name:RIDER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:P O BOX 577
Mailing Address - Street 2:
Mailing Address - City:CARTERVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62918-0577
Mailing Address - Country:US
Mailing Address - Phone:618-985-8221
Mailing Address - Fax:
Practice Address - Street 1:1700 WILDCAT DR
Practice Address - Street 2:
Practice Address - City:MARION
Practice Address - State:IL
Practice Address - Zip Code:62959-1506
Practice Address - Country:US
Practice Address - Phone:618-969-8228
Practice Address - Fax:618-998-0880
Is Sole Proprietor?:No
Enumeration Date:2006-08-20
Last Update Date:2017-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085-000677363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL101081OtherHEALTH ALLIANCE
IL370966854023Medicaid
IL640701OtherPTAN MEDICAARE
ILCF3444OtherMEDICARE RR
IL370966854014Medicaid
IL141106Medicare Oscar/Certification
ILCF3444OtherMEDICARE RR
IL101081OtherHEALTH ALLIANCE
IL370966854014Medicaid