Provider Demographics
NPI:1124261219
Name:MARYVILLE PHYSICIANS SERVICES INC
Entity type:Organization
Organization Name:MARYVILLE PHYSICIANS SERVICES INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
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 1:1836 LACKLAND HILL PKWY
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63146-3572
Mailing Address - Country:US
Mailing Address - Phone:314-989-0300
Mailing Address - Fax:
Practice Address - Street 1:6812 STATE ROUTE 162
Practice Address - Street 2:SUITE 123
Practice Address - City:MARYVILLE
Practice Address - State:IL
Practice Address - Zip Code:62062-8553
Practice Address - Country:US
Practice Address - Phone:618-288-9460
Practice Address - Fax:618-288-9461
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MARYVILLE PHYSICIANS SERVICES INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2009-04-20
Last Update Date:2010-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL6293420001Medicare NSC