Provider Demographics
NPI:1831596733
Name:MARKET STREET MEDICAL, LLC
Entity type:Organization
Organization Name:MARKET STREET MEDICAL, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:KELLY
Authorized Official - Middle Name:S
Authorized Official - Last Name:EYER
Authorized Official - Suffix:
Authorized Official - Credentials:FNP-BC
Authorized Official - Phone:618-392-2395
Mailing Address - Street 1:117 E MARKET ST
Mailing Address - Street 2:
Mailing Address - City:OLNEY
Mailing Address - State:IL
Mailing Address - Zip Code:62450-2241
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:117 E MARKET ST
Practice Address - Street 2:
Practice Address - City:OLNEY
Practice Address - State:IL
Practice Address - Zip Code:62450-2241
Practice Address - Country:US
Practice Address - Phone:618-392-1301
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-11-21
Last Update Date:2014-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209012101261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center