Provider Demographics
NPI:1831840180
Name:MARYVILLE IMAGING, LLC
Entity type:Organization
Organization Name:MARYVILLE IMAGING, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:DALE
Authorized Official - Last Name:ENGELKE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:618-635-4242
Mailing Address - Street 1:6800 STATE ROUTE 162
Mailing Address - Street 2:
Mailing Address - City:MARYVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62062-8500
Mailing Address - Country:US
Mailing Address - Phone:618-288-4929
Mailing Address - Fax:
Practice Address - Street 1:3417 ANDERSON HEALTHCARE DR
Practice Address - Street 2:
Practice Address - City:EDWARDSVILLE
Practice Address - State:IL
Practice Address - Zip Code:62025-7784
Practice Address - Country:US
Practice Address - Phone:618-288-4929
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MARYVILLE IMAGING, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2022-01-18
Last Update Date:2022-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0200XAmbulatory Health Care FacilitiesClinic/CenterRadiology