Provider Demographics
NPI:1629217179
Name:MT. VERNON OB-GYN LLC
Entity Type:Organization
Organization Name:MT. VERNON OB-GYN LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:J
Authorized Official - Last Name:SCHIFANO
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:618-997-5266
Mailing Address - Street 1:3408 OFFICE PARK DRIVE
Mailing Address - Street 2:
Mailing Address - City:MARION
Mailing Address - State:IL
Mailing Address - Zip Code:62959
Mailing Address - Country:US
Mailing Address - Phone:618-997-5266
Mailing Address - Fax:618-997-5285
Practice Address - Street 1:1407 MCPHERSON AVENUE
Practice Address - Street 2:
Practice Address - City:MT. VERNON
Practice Address - State:IL
Practice Address - Zip Code:62864
Practice Address - Country:US
Practice Address - Phone:618-997-5266
Practice Address - Fax:618-997-5285
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-02-06
Last Update Date:2011-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1920Medicare PIN