Provider Demographics
NPI:1154642411
Name:MARION PEDIATRIC CLINIC SC
Entity Type:Organization
Organization Name:MARION PEDIATRIC CLINIC SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:LUIS
Authorized Official - Middle Name:A
Authorized Official - Last Name:LOPEZ
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:618-993-5274
Mailing Address - Street 1:3331 W DEYOUNG ST STE 207
Mailing Address - Street 2:
Mailing Address - City:MARION
Mailing Address - State:IL
Mailing Address - Zip Code:62959-5897
Mailing Address - Country:US
Mailing Address - Phone:618-993-5274
Mailing Address - Fax:618-993-0639
Practice Address - Street 1:3331 W DEYOUNG ST STE 207
Practice Address - Street 2:
Practice Address - City:MARION
Practice Address - State:IL
Practice Address - Zip Code:62959-5897
Practice Address - Country:US
Practice Address - Phone:618-993-5274
Practice Address - Fax:618-993-0639
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-06-21
Last Update Date:2010-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036103701208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILG27922Medicare UPIN