Provider Demographics
NPI:1447203971
Name:MIRLY, HARVEY LEE (MD)
Entity Type:Individual
Prefix:DR
First Name:HARVEY
Middle Name:LEE
Last Name:MIRLY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4700 MEMORIAL DR
Mailing Address - Street 2:STE. 340
Mailing Address - City:BELLEVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62226-5373
Mailing Address - Country:US
Mailing Address - Phone:618-234-9884
Mailing Address - Fax:618-235-9020
Practice Address - Street 1:4700 MEMORIAL DR
Practice Address - Street 2:STE. 340
Practice Address - City:BELLEVILLE
Practice Address - State:IL
Practice Address - Zip Code:62226-5373
Practice Address - Country:US
Practice Address - Phone:618-235-7065
Practice Address - Fax:618-235-9020
Is Sole Proprietor?:No
Enumeration Date:2006-05-18
Last Update Date:2021-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036085921207XS0106X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XS0106XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryHand Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1447203971Medicaid
IL6394100002OtherMEDICARE DME
IL1447203971Medicaid
ILIL3501006Medicare PIN