Provider Demographics
NPI:1487047627
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:A
Authorized Official - Last Name:PAGE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:866-916-5259
Mailing Address - Street 1:PO BOX 537
Mailing Address - Street 2:
Mailing Address - City:EDWARDSVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62025-0537
Mailing Address - Country:US
Mailing Address - Phone:800-210-7034
Mailing Address - Fax:
Practice Address - Street 1:2504 COMMERCE
Practice Address - Street 2:
Practice Address - City:HIGHLAND
Practice Address - State:IL
Practice Address - Zip Code:62249-0017
Practice Address - Country:US
Practice Address - Phone:618-651-9777
Practice Address - Fax:618-651-3419
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-03-12
Last Update Date:2015-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency MedicineGroup - Multi-Specialty