Provider Demographics
NPI:1467409599
Name:MARCINCZYK, MARIO J (MD)
Entity type:Individual
Prefix:
First Name:MARIO
Middle Name:J
Last Name:MARCINCZYK
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:PO BOX 1125
Mailing Address - Street 2:
Mailing Address - City:MARYLAND HEIGHTS
Mailing Address - State:MO
Mailing Address - Zip Code:63043-0125
Mailing Address - Country:US
Mailing Address - Phone:888-731-1036
Mailing Address - Fax:423-892-5838
Practice Address - Street 1:1 MEMORIAL DR
Practice Address - Street 2:
Practice Address - City:ALTON
Practice Address - State:IL
Practice Address - Zip Code:62002-6722
Practice Address - Country:US
Practice Address - Phone:618-463-7311
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-26
Last Update Date:2023-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2005024595207L00000X
IL036.095452207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036095452Medicaid
MO203133OtherBCBS
MO207562307Medicaid
P00316808OtherRR MEDICARE
IL036095452Medicaid
MO207562307Medicaid
MOG01076Medicare UPIN