Provider Demographics
NPI:1023055696
Name:NOVAMED EYE SURGERY CENTER OF MARYVILLE, LLC
Entity type:Organization
Organization Name:NOVAMED EYE SURGERY CENTER OF MARYVILLE, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE VP AND CFO
Authorized Official - Prefix:MR
Authorized Official - First Name:SCOTT
Authorized Official - Middle Name:T
Authorized Official - Last Name:MACOMBER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:312-780-3234
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 MARYVILLE PROFESSIONAL PARK
Practice Address - Street 2:
Practice Address - City:MARYVILLE
Practice Address - State:IL
Practice Address - Zip Code:62062
Practice Address - Country:US
Practice Address - Phone:618-288-7483
Practice Address - Fax:618-288-7196
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:NOVAMED, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-06-01
Last Update Date:2008-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL7002132367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified RegisteredGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL0006032183OtherBCBS OF IL
IL0006032183OtherBCBS OF IL
IL=========001Medicaid
IL0006032183OtherBCBS OF IL