Provider Demographics
NPI:1780614669
Name:MARYVILLE MEDICAL SERVICES, LLC
Entity type:Organization
Organization Name:MARYVILLE MEDICAL SERVICES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:KEITH
Authorized Official - Middle Name:
Authorized Official - Last Name:PAGE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:618-288-5711
Mailing Address - Street 1:6810 STATE ROUTE 162
Mailing Address - Street 2:SUITE 215
Mailing Address - City:MARYVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62062-8501
Mailing Address - Country:US
Mailing Address - Phone:618-288-5711
Mailing Address - Fax:618-288-4088
Practice Address - Street 1:6810 STATE ROUTE 162
Practice Address - Street 2:SUITE 215
Practice Address - City:MARYVILLE
Practice Address - State:IL
Practice Address - Zip Code:62062-8501
Practice Address - Country:US
Practice Address - Phone:618-288-5711
Practice Address - Fax:618-288-4088
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-04
Last Update Date:2008-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified RegisteredGroup - Multi-Specialty
No103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL208901Medicare ID - Type UnspecifiedGROUP MEDICARE NUMBER