Provider Demographics
NPI:1760550222
Name:MARION MEDICAL XRAY
Entity Type:Organization
Organization Name:MARION MEDICAL XRAY
Other - Org Name:MARION MEDICAL XRAY
Other - Org Type:Other Name
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:JUDY
Authorized Official - Middle Name:KAY
Authorized Official - Last Name:BRANDON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:618-997-6909
Mailing Address - Street 1:1008 W CHERRY ST
Mailing Address - Street 2:
Mailing Address - City:MARION
Mailing Address - State:IL
Mailing Address - Zip Code:62959-1998
Mailing Address - Country:US
Mailing Address - Phone:618-997-6909
Mailing Address - Fax:618-997-7759
Practice Address - Street 1:1008 W CHERRY ST
Practice Address - Street 2:
Practice Address - City:MARION
Practice Address - State:IL
Practice Address - Zip Code:62959-1998
Practice Address - Country:US
Practice Address - Phone:618-997-6909
Practice Address - Fax:618-997-7759
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-01
Last Update Date:2007-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL2085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL693272OtherMEDICARE GROUP PROVIDER #
IN164921OtherFDA
271836OtherHEALTHLINK
IL1052274OtherUMWA
IL2800075OtherBLUE CROSS BLUE SHIELD
IL863211OtherDEPT OF LABOR
IL0360443201Medicaid
IL863211OtherDEPT OF LABOR
271836OtherHEALTHLINK