Provider Demographics
NPI:1386641066
Name:EYE SURGERY CENTER OF MARYVILLE LLC
Entity Type:Organization
Organization Name:EYE SURGERY CENTER OF MARYVILLE LLC
Other - Org Name:EYES OF ILLINOIS SURGERY CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VP, CMO
Authorized Official - Prefix:
Authorized Official - First Name:JOSEPH
Authorized Official - Middle Name:PRAVOOT
Authorized Official - Last Name:GIRA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:314-909-0633
Mailing Address - Street 1:12 PROFESSIONAL PARK DR
Mailing Address - Street 2:
Mailing Address - City:MARYVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62062-5672
Mailing Address - Country:US
Mailing Address - Phone:618-288-7483
Mailing Address - Fax:618-288-7196
Practice Address - Street 1:12 PROFESSIONAL PARK DR
Practice Address - Street 2:
Practice Address - City:MARYVILLE
Practice Address - State:IL
Practice Address - Zip Code:62062-5672
Practice Address - Country:US
Practice Address - Phone:618-288-7483
Practice Address - Fax:618-288-4583
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-07
Last Update Date:2024-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL7002132261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
P00127048OtherRR MEDICARE
P00127048OtherRR MEDICARE
IL=========001Medicaid