Provider Demographics
NPI:1669520060
Name:DR. MARY MIOUX-BERRY, LLC
Entity type:Organization
Organization Name:DR. MARY MIOUX-BERRY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MARY
Authorized Official - Middle Name:A
Authorized Official - Last Name:MIOUX-BERRY
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:618-288-3610
Mailing Address - Street 1:3407 S STATE ROUTE 157
Mailing Address - Street 2:SUITE 3
Mailing Address - City:GLEN CARBON
Mailing Address - State:IL
Mailing Address - Zip Code:62034-1042
Mailing Address - Country:US
Mailing Address - Phone:618-288-3610
Mailing Address - Fax:
Practice Address - Street 1:3407 S STATE ROUTE 157
Practice Address - Street 2:SUITE 3
Practice Address - City:GLEN CARBON
Practice Address - State:IL
Practice Address - Zip Code:62034-1042
Practice Address - Country:US
Practice Address - Phone:618-288-3610
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-08
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL=========OtherTAX ID